It gives a comprehensive summary of assessment and principles of management of hand injuries. It is useful material for those in surgical practice.

1. MANAGEMENT OF ACUTE
HAND INJURIES
By Ruhama Yoseph (R
IV)
July, 2014

2. OUTLINE
 Introduction
 Clinical Assessment of injuries
 Surgical Anatomy
 General Principle of Management
 Types of Hand Injuries
 Management of Specific injuries
◦ Fractures & Dislocations
◦ Soft Tissue Reconstruction
◦ Tendon injuries
7/1/2014 2

3. Introduction
 Contribute to 5-10% ED visits in
Western countries
 The importance of functionality of the
hand can’t be over emphasized
 Meticulous evaluation, care and
dedicated rehabilitation are rewarding
in hand injuries
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4. Clinical Assessment
 Brief History….
◦ Mechanism of trauma
◦ Age
◦ ‘Handedness’ of patient
◦ Occupation
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5. Clinical Assessment
 Examination…
Superficial injuries and obvious
deformities can be easily detected.
But deeper injuries need time taking
examination to disclose them.
7/1/2014 5

6. Clinical Assessment
 Examination…
◦ Circulation
◦ Soft-tissue cover
◦ Bones
◦ Joints
◦ Nerves
◦ Tendons
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7. Movements of the Hand
 Pinch
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8. Movements of the Hand
 Key
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9. Movements of the Hand
 Tripod
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10. Movements of the Hand
 Grasp
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11. Movements of the Hand
 Power grip
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12. Movements of the Hand
 Resting position of the hand during
flexion and extension
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13. Movements of the Hand
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14. Movements of the Hand
 Thumb movements
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15. Movements of the Hand
 FDP & FDS test for lesser fingers
 FDP & FDS test for index finger
7/1/2014 15

16. Radiologic Assessment
 Standard view of AP, Lateral &
Oblique should be done
7/1/2014 16

17. Radiologic Assessment
 CT scan offers better information
about carpo-metacarpal
fracture/dislocations
7/1/2014 17

18. Anatomy of the hand
 Bones
◦ Composed of 19 bones & 8 carpal Bones
7/1/2014 18

19. Anatomy of the hand
◦ Ligaments
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20. Anatomy of the hand
 Tendons
7/1/2014 20

21. Anatomy of the hand
 Tendons
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22. Anatomy of the hand
 Carpal Tunnel
7/1/2014 22

23. Anatomy of the hand
 The neurovascular bundles lay volar to the midaxis
of the digit with the artery dorsal to the nerve
 Grayson's ligament (volar) and Cleland's ligament (dorsal)
connect the bone to the skin surrounding the bundle
7/1/2014 23

24. General principles of management
 Circulation
◦ If threatened prompt restoration should be
done with micro-vascular techniques
◦ An example is when there is a crush injury
of the proximal hand with disruption of the
distal blood supply but an otherwise
normal tissue.
◦ Salvage of digits by using vein grafts
bridging the zone of damage will
contribute for the ultimate function of the
hand
7/1/2014 24

25. General principles of management
 Swelling
◦ Hand elevation initially, and early initiation
of repetitive active hand exercise to
prevent stiffness
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26. General principles of management
 Splinting
◦ Wrong splintages can potentially lead to
hand stiffness
◦ ‘ Position of Safety’- MCP joints flexed to
90 degrees and the IP joints left almost
straight
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27. 7/1/2014 27

28. General principles of management
 Nerve and Tendon injury
◦ Primary repair always has best results
depending on the patient and injury factor
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29. General principles of management
 Skin cover
◦ Takes precedence than deeper structure
injuries
◦ Skin cover takes priority over “healing by
secondary intention” because of the
undesired infection and fibrosis
results
◦ Early wound toilet and suturing or
reconstruction with grafts or flaps
depending on the type of injury is
advantageous
7/1/2014 29

30. Types of hand injuries
 Three main types depending on injury
patterns:
◦ Cutting and Slicing
◦ Crushing
◦ Degloving and Avulsion
 Or they can be classified as Tidy and
Untidy wounds
7/1/2014 30

31. Tidy injury
 Damage to the skin is clear-cut
 Usually tendons and nerves are
injured which necessitates their
immediate repair and reconstruction
 For a bloodless field during
reconstruction pneumatic tourniquet is
used
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32. Untidy Injury
 Initial assessment includes deciding
which tissues are viable
 The non-viable tissue should be
removed
 Skin after injury though without blood
supply remains viable. So if undamaged it
is worth considering its reapplication to the
debrided surface as a full thickness skin
graft after de-fatting it.
7/1/2014 32

33. Cutting & Slicing Injuries
 If without skin loss, the wound can be
closed primarily after sufficient
excision of devitalized tissue
 If bed exposed is suitable for grafting ,
then split thickness is used for primary
coverage
 The minimal tissue damage expected
allows definitive repair of tendons or
nerves.
7/1/2014 33

34. Cutting & Slicing Injuries
 When raw area includes structure
unsuitable grafting, flap cover should
be provided
 Examples are pulp of finger tip, exposed
tendon…
 For injury resulting in guillotine
amputation of a finger, the preferred
option is trimming the phalanx and
doing soft tissue reconstruction
7/1/2014 34

35. Cutting & Slicing Injuries
 But the greater the number of fingers
amputated, the greater the need to
conserve the length of individual
fingers
 For thumb injuries, maintaining the
length for gaining a good length
opposable thumb is emphasized
 No excessive trimming and use of skin
grafts as temporary measures for
covering tip is recommended
7/1/2014 35

36. Crushing Injuries
 Ultimate loss is much greater than the
immediately apparent
 Can be mild as subungual hematoma
or severe as a power-press injury
leaving a shapeless pulp
 The ‘hidden’ damage has
consequence of severe edema post-
op and fibrosis later with disappointing
functional result
7/1/2014 36

37. Crushing Injuries
 Immediate management involves
ruthless debridement of non-viable
tissue
 Second assessment will be done
where the decision of preserving
damaged but viable structures will be
done
 There are two contending ideas
regarding the salvage of digits…
7/1/2014 37

38. Crushing Injuries
1) Amputation of a finger even when
viable but with damage of individual
components (nerve, tendon, skin,
bone)
2) Retention of individual digit even in
the knowledge that it will be stiff
when there is a greater damage to
other fingers and the rest of the hand
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39. Crushing Injuries
 Grafts are less likely to take in the
presence of crush injury in the early
post-op periods
 In conclusion, crushing injury carries a
much longer period of disability and
poorer results with stiffness and
function
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40. Degloving & Avulsion Injuries
 The distinction between degloving and
avulsion injuries lies in the tissue
involved
 Degloving
◦ Confined to the skin & fascia
◦ Important pathological factor is disruption
of blood vessels
◦ Damage to tendon, bone and joints is not
typical pattern
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41. Degloving & Avulsion Injuries
 Avulsion
◦ Involves the deeper tissues like tendons,
muscle, nerves
◦ Can be combined degloving/avulsion
injury as in pulling out of a digit
◦ Such a digit can be salvageable with
microsurgery depending on the severity of
the neurovascular damage
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42. Degloving & Avulsion Injuries
 Dorsum and palm have different
coping capacity
 Palm
◦ Degloving plane between palmar aponeurosis
(as a single structure attached to skin) and flexor
tendon
◦ The strength and relative inextensibility of the
aponeurosis protects the circulation of the
overlying skin
 Dorsum:
◦ Degloving plane leaves the extensor tendons
exposed within their paratenon
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43. Degloving & Avulsion Injuries
 After injury, assessment of skin
viability is difficult, the common
mistake being underestimation
 Early excision and skin cover is good
for rapid healing
 Delayed primary treatment, waiting the
necrotic area to declare itself, is
another option
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44. Degloving & Avulsion Injuries
 Split thickness graft is usual form of
cover at the acute stage, and
sometimes for permanency
 Primary flap considered if bare
tendon, cortical bone or open joint is
present
7/1/2014 44

45. Degloving & Avulsion Injuries
 Degloving of ring finger…by a fixed
ring
◦ Injury may involve phalangeal fracture,
partial or complete stripping off the skin
◦ Management of skeletonized finger but
intact tendon and joint function depends
on the availability of micro-vascular
expertise
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46. Degloving & Avulsion Injuries
 If skin still attached distally, it can be re-
vascularized by bridging lost veins and
arteries, while at the same time suturing
nerves
 If expertise unavailable or if attempt fails,
amputation is advised
7/1/2014 46

47. Degloving & Avulsion Injuries
 A degloved thumb needs special Mx
Temporary salvage of skeletonized thumb by
‘burying’ it under the skin of abdomen or chest
Inserting the thumb into a tubed flap like groin,
delto-pectoral or random pattern flaps
A neurovascular ‘island’ flap by using the hemi-
pulp of a functionally less important finger, brings
sensation and blood supply to the tip of the
thumb
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48. Degloving & Avulsion Injuries
Transfer of big toe or the second toe are
other options to replace an amputated
or near amputated thumb
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49. Degloving & Avulsion Injuries
 Dorsum of hand:
◦ Degloving plane leaves the extensor
tendons exposed within their paratenon
◦ This is suitable for early grafting
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50. Finger tip injuries
 Contribute to significant percentage of
upper extremity injuries
 The integrity of the three elements of
the distal segment of digit is essential
◦ Pulp
◦ Nail
◦ Phalanx
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51. Finger tip injuries
◦ Smoothness and integrity of nail-bed is
crucial
◦ Once the generative element of nail is
damaged irregular and patchy growth
develops
◦ Nail beds should be repaired before
replacing back of nails
◦ Immobilization of distal phalanx fracture
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52. FRACTURES

53. FRACTURES
 Things special about hand fractures
◦ Consist of small fragments often difficult
for anatomical reduction
◦ Risk of tendon and joint adhesions with
sequela of function impairment
◦ Surgical incision itself can cause function
limiting scar formation
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54. FRACTURES
 The goals in treatment of metacarpal
and phalangeal fractures:
◦ Restoration of articular anatomy
◦ Elimination of angular and rotational
deformity
◦ Stabilization of fracture
◦ Surgically acceptable wound
◦ Rapid mobilization
7/1/2014 54

55. Metacarpal fractures
 Majority of fractures are closed, simple and
stable
◦ Brief immobilization followed by active exercises
suffices for management of those
 Mechanisms
◦ Blows, falls on the hand, boxers punch…
 Common sites of fracture
◦ Base, neck or shaft
 Rotational deformity is a serious problem ,
whereas angular deformity is not of major
concern
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56. Metacarpal fractures
a) Spiral metacarpal fracture
b) Oblique metacarpal fracture
c) Multi-fragmented metacarpal fracture
d) Simple articular fracture
e) Bicondylar fracture
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57. Metacarpal fractures
 Indications for operative stabilization
◦ Significant displacement
 2nd & 5th metacarpal fractures are liable to
shortening
 Angulations of >30o& shortening >4mm or a
combination of the two are not tolerated
◦ Rotational malalignment
 As little as 5o rotation results in 1.5 cm finger
overlap during flexion
◦ Multiple fractures
◦ Gross deformities
◦ Association with significant soft tissue injury
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58. Metacarpal fractures
 Surgical approaches
a) Incisions for individual metacarpal exposure
b) Incisions for exposure of all metacarpals
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59. Metacarpal shaft fractures
 They tend to angulate with the apex
dorsally due to the pull of intrinsic
muscles of the hand
 In the 4th & 5th fingers up to 20
degrees angulations are acceptable
 Index & middle fingers, only up to 5 -
10 degrees acceptable
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60. Metacarpal shaft fractures
 Transverse/ oblique fractures with slight
displacement
◦ Crepe bandage with active mobilization
 Transverse fractures with displacement
◦ Reduction and splint immobilization of the
involved finger/s for 3 wks
◦ If unstable one, operative management
preferred (compression plates or K-wire)
 Spiral fractures
◦ Operative management (plate, lag screws,
percutaneous K-wiring)
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61. Metacarpal shaft fractures
 K-wire fixation of unstable transverse
metacarpal fracture
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62. Metacarpal shaft fractures
 Spiral fractures of ring &
long finger metacarpals
with rotational
deformities
 Lag screw fixations
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63. Metacarpal neck fractures
 Patients present with pain and
flattening of knuckles
 Boxer’s fracture- the 5th digit is
involved
 Are fairly unstable fractures with volar
angulations because of the
unproportional pool of flexor tendons
and typically volar communition
character of the fracture
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64. Metacarpal neck fractures
 Boxer’s fracture which should be
treated with early mobilization
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65. Metacarpal neck fractures
 4th and 5th digits:
◦ As much as 40 degrees angulations
acceptable since their main function is in
flexion, Power grip
◦ Splint for 2wks with flexion of MCP joint
and extension of IP joints
 Index and middle fingers
◦ Since their functionality is mainly at
extension only 20 degrees angulations
are tolerated
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66. Metacarpal neck fractures
 First reduction after a local block
 If it redisplaces, fixation with two or
three bent wires passed distally
through a hole in the styloid process of
the fifth metacarpal base is particularly
effective
 Complication, usually malunion
◦ Volar angulations of the distal fragment
◦ The digit may assume ‘Z appearance’
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67. Metacarpal head fractures
 Brewerton X-ray view
◦ Obtained by flexing MCP joint to see
articular detail
◦ Intra-articular fracture is common, and
thus ORIF recommended
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68. Metacarpal base fractures
 Extra-articular ones are usually stable
because of their impaction
◦ But if multiple or intrinsic capsular ligaments
disrupted fracture should be fixed with plates
 Intra-articular fractures are common on the
5th digit
◦ The option of operative management is
distraction with ex-fix & grafting of the defect
7/1/2014 68

69. Metacarpal base fractures
 Multiple extra-articular metacarpal base fractures
fixed with mini-condylar plates
7/1/2014 69

70. Fractures of the Phalanx
 Their typical features are:
◦ Unstable fractures tend to angulate
dorsally
◦ They are prone to adhesion & stiffness
◦ Fracture displacement is less tolerated at
phalanx than metacarpal
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71. Fractures of the Phalanx
 Cross-section through the proximal phalanx
showing the proximity of the tendon sheaths to the
bone
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72. Fractures of the Phalanx
 For reducible and stable injuries
◦ 3 wks immobilization with cast or splint
followed by gentle mobilization with
interval protective splinting
◦ Hand based functional splint for proximal
phalanx fractures
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73. Fractures of the Phalanx
 For reducible & unstable injuries:
◦ Per cutaneous K-wire fixation
◦ Limited internal fixation with screws
known as
“closed reduction & internal fixxation”
◦ External fixation
7/1/2014 73

74. Fractures of the Phalanx
 Per-cutaneous pinning
7/1/2014 74

75. Soft Tissue Reconstruction of
the Hand

76. Soft Tissue Reconstruction
 The objective is to achieve primary
wound healing since it
◦ Decreases inflammatory reaction
◦ Decreases scar formation
◦ Decreases joint stiffening
 The tiers of surgical approach:
Primary Closure Skin Graft Flap Free Tissue
Transfer
Depending on injury and patient factors
7/1/2014 76

77. Soft Tissue Reconstruction
 Principles of replacement:
As early as possible, but not when
tissue viability is questionable
 Donor sites:
Hand itself is superior
Because it has the best tissue match, recovery of
sensibility, and simplicity for wound care
7/1/2014 77

78. Skin Grafts
 Dorsal and volar skin of the hand have
different requirements
Dorsal Skin Volar Skin
Thin Thicker
Loose enough not to restrict
flexion
Tougher but allowing motion
Protecting tendons and
joints
Increased sensibility
because of its encapsulated
nerve endings
Absence of pilo-sebaceous
units
7/1/2014 78

79. Skin Grafts
 Split Thickness Skin Graft:
◦ Are thin, usually 0.015 inch thick
recommended for adults
◦ Used for covering major defects
◦ Immobilization is an important technical
factor for taking of grafts
7/1/2014 79

80. Skin Grafts
 Full Thickness Skin Graft:
◦ Advantages are:
 Increases sensibility
 Decreases contraction
 Thicker protected tissue covering
◦ But these can be used for small defects
only
◦ Donor sites for glabrous skin:
 Hypothenar eminence, non-weight bearing
instep of the foot, volar surface of wrist,
hairless inguinal fold skin
7/1/2014 80

81. Flaps
 Three indications
1. Wound unsuitable for re-vascularization of
a skin graft
2. Need to replace subcutaneous tissue as
well as skin
3. Protection required of an exposed vital
structure like nerve or joint
Donor sites can be local, regional or
distant
7/1/2014 81

82. Flaps
 Technical considerations:
◦ Planning starts by measuring the patterns
of the recipient site
◦ Cutting should be done deep to the
level/plane of fascia
◦ Sharp dissection elevating it from deep
fascia within the layer of areolar tissue
◦ Severing of pedicled flaps can be done on
10-14th day for local flaps & 14-21st day
for distant flaps
7/1/2014 82

83. Local Flaps
 Bilateral V-Y Advancement Flaps:
◦ For transverse finger tip amputations or for
slightly volar amputations at mid-nail level
◦ Cut from the sides of the injured finger and
advanced over the tip by dividing the fibrous
septa
7/1/2014 83

84. Local Flaps
 Volar V-Y Advancement Flap
◦ For transverse or dorsally directed finger tip
amputation at mid-nail level
◦ A ‘V’ shaped flap raised with its tip at crease of
DIP joint, septa divided from underlying phalanx
and flap advanced
7/1/2014 84

85. Local Flaps
 Moberg Flap ( Volar Neurovascular
Advancement Flap)
◦ For thumb tip injury
◦ Volar aspect of remaining skin raised from
flexor tendon sheath including the
neurovascular bundle on both sides
◦ Base of flap is MCP joint crease
This is not suitable for other fingers
since it causes necrosis of dorsal skin
7/1/2014 85

86. Local Flaps
 Moberg Flap …
7/1/2014 86

87. Local Flaps
 Cross-Finger Flap
◦ For cases of volar finger-tip amputations
◦ The dorsal skin over the middle phalanx
of an adjoining finger is elevated above
the extensor peritenon
◦ It is taken like a page of an open book
and sutured on the tip of injured finger
which is positioned in flexion
◦ Donor grafted and flap divided on 9-10th
day
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88. Local Flaps
 Cross-Finger Flap…
7/1/2014 88

89. Local Flaps
 Reversed Cross-Finger Flap
◦ For soft tissue coverage of dorsal finger
injuries
◦ A standard cross-finger flap is designed
and de-epithelialized.
◦ Flap is then elevated in a routine fashion
and turned 180 degrees upside down
◦ The donor defect and undersurface of the
flap are then skin grafted
7/1/2014 89

90. Local Flaps
 Volar Cross-Finger Flap
◦ For thumb tip injuries, flap is constructed
from volar surface of middle finger above
the middle or proximal phalanx
◦ Immobilization is maintained at
comfortable position
7/1/2014 90

91. Local Flaps
 Volar Cross-Finger Flap…
7/1/2014 91

92. Local Flaps
 Dorsal cross-finger flaps
have blood supply of
longitudinal distribution
 Volar-cross-finger flaps get
blood supply form vertically
oriented vessels and
therefore flap size is limited
 Also pedicle of flap is in
close proximity of the
neurovascular bundle
7/1/2014 92

93. Local Flaps
 Flag Flap
◦ axial flaps based on the dorsal branches
of the digital vessels, allowing for a very
narrow pedicle and thus a mobile flap
7/1/2014 93

94. Local Flaps
 Thenar Flap
◦ Excellent for covering defect of major
phalangeal amputations
◦ It has the best tissue match with sufficient
subcutaneous tissue
◦ To prevent stiffness, the MCP of recipient
finger should be fully flexed
◦ Flap is proximally based taken from the
highest point of thenar eminence with its
lateral border at MCP crease
7/1/2014 94

95. Local Flap
 Thenar Flap
7/1/2014 95

96. Local Flap
 Neurovascular Island Flap
◦ Sensate, vascularized tissue from the
ulnar side of the ring or long finger is
transferred to the thumb in a single stage
◦ The digital proper branch of sensory
nerve is used
7/1/2014 96

97. Local Flap
 Neurovascular Island Flap
7/1/2014 97

98. Distant Flap
 Three types
◦ Axial Flaps
Those with specific vascular pedicle
◦ Random Flaps
No specific vascular pedicle
◦ Free Flaps
7/1/2014 98

99. Distant Flap
 Axial Flaps
◦ Superficial Inferior Epigastric Artery Flap
◦ Superficial Circumflex Iliac Artery Flap
( Groin Flap)
◦ Lateral Thoracic Artery Flap
7/1/2014 99

100. Distant Flap
 Axial Flap
7/1/2014 100

101. Distant Flap
 Superficial Inferior Epigastric Artery
Flap
◦ Preferred if situated on the contra-lateral
side of the injured hand
◦ Causes minimal shoulder and elbow pain
◦ Upto 12 cm wide donor defect can be
closed directly
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102. Distant Flap
 Superficial inferior epigastric artery
flap
7/1/2014 102

103. Distant Flap
 Superficial Circumflex Iliac Artery Flap
( Groin Flap)
◦ Advantage is that it is a flap with minimal
hair transfer
◦ Up to 15 cm wide defects can be closed
directly
◦ Has problem with elbow and shoulder
discomfort
7/1/2014 103

104. Distant Flap
 Superficial Circumflex Iliac Artery Flap
( Groin Flap)
7/1/2014 104

105. Distant Flap
 Lateral Thoracic Artery Flap
◦ Contralateral to injury side is used
◦ Superior based flap following the down
course of the artery on the lateral wall of
the chest
◦ Position is well tolerated, but has bad
cosmetic results
7/1/2014 105

106. Distant Flap
 Lateral Thoracic Artery Flap
7/1/2014 106

107. Random Flap
 Abdominal source
◦ Superior or inferior based flap with length
to width ratio of 1.5:1
 Medial surface of Contralateral arm
◦ The good vascularity of the area allows
flaps to be elvated with length to width
ratio of 2:1
7/1/2014 107

108. Free Flap
 Provides wound coverage as well as
transfer of bone, nerve and tendons
 A commonly used free tissue transfer for
hand reconstruction is the fasciocutaneous
lateral arm flap, which is supplied by the
posterior radial collateral artery, a branch of
the profundi brachial artery
7/1/2014 108

109. Free Flap
 Lateral arm flap supplied by the posterior radial
collateral artery
7/1/2014 109

110. TENDON INJURIES

111. TENDON INJURIES
 The tendon repair must be strong and
accurate enough to allow early
mobilization (usually passive) so that
the tendons can glide freely and
independently from each other and the
sheath
7/1/2014 111

112. TENDON INJURIES
 Primary repair
In first 24 hours time
 Delayed Primary repair
Within 24 hrs to 10 days period
 Secondary repair
After 10-14 days
7/1/2014 112

113. TENDON INJURIES
 Three phases of intrinsic healing in
tendon repair:
1. Inflammatory (48-72 hrs)
2. Fibroblastic (5 days-4 wks)
3. Remodeling (4wks- 3.5 mo)
 Extrinsic activity by peripheral
fibroblasts plays the role in formation
of adhesion and scars
7/1/2014 113

114. TENDON INJURIES
 Important technical aspects
◦ Minimal handling with instruments
◦ Smooth juncture of two ends
◦ Secure knots
◦ Minimal interference with vascularity of
tendon
◦ Proper suture material
7/1/2014 114

115. TENDON INJURIES
 Kessler grasping
suture
 Bunnel suture
 Modified Kessler
suture
 Fish-mouth E-to-E
suture (PluverTaft)
7/1/2014 115

116. Flexor Tendon Injury
 Incisions for
exploration of the
hand
7/1/2014 116

117. Flexor Tendon Injury
 Repair of flexor tendons is difficult in the
region labeled as “No-Man’s Land” or Zone
II
◦ Here both SFD & PFD run together in a
single sheath
◦ Primary repair and specialized post-op
physiotherapy bring good results
7/1/2014 117

118. Flexor Tendon Injury
 No-Mans Land:
Between the distal palmar crease and the flexor crease of the
proximal inter-phalangeal joint
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119. Flexor Tendon Injury
 Flexor tendon sheath and pulleys
◦ Five annular and three cruciate pulleys
◦ From these, A2 & A4 are important tethering effect
and must be preserved or always repaired
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120. Extensor Tendon Injury
 There are 8 zones the odd numbered ones
lying over joints
 Repair is relatively easier since tendon
ends are less likely to retract
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121. Extensor Tendon Injury
Mallet Finger
Dropped fingers from
extensor tendon rupture
Swan-neck deformities
Boutonniere deformity
EPB rupture
EPL rupture
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122. Extensor Tendon Injury
 Mallet finger results from avulsion of
extensor tendon from its insertion
 Stack Splint for 6-8 wks suffices for
management
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123. Extensor Tendon Injury
 Button-hole deformity- results from
rupture of central slip of extensor
expansion
 Loss of extension of PIP and thus
persistent flexion
 Hyperextension of DIP joint
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124. REFERENCES
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125. THANK YOU!
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