Management of hand injuries

Inspect the Attitude of Hand for;

  • Resting position of digits.
  • Any deformity, swelling or asymmetry.
Assess the vascular status by examining.
  • Color
  • Capillary Refill (1-2 seconds)
  • Temperature
  • Pulses
  • Allen’s Test (To verify palmer arches)
Assess Neurological Status
Do motor examination, both active and passive, to see integrity of tendons and nerves (Ulnar, Median & Radial)
Check Sensation by two-point discrimination, light touch, and absence of sweating (in children)
  • Assess skeleton by palpating for any tenderness or deformity.
  • Assess joints by stressing ligament and noting any instability, crepitus or pain.
  • Clinically if there is any suspicion of fracture or dislocation request for plain X-Ray of hand AP & oblique views.
Primary Treatment
Preoperative Care
  • Treat pain with injectable analgesia.
  • For contaminated wounds start I/V antibiotics covering Staph. aureus like Ampiclox cefuroxine etc.
  • Tetanus prophylaxis.
  • Light splintage.
  • Cover wound with sterile dressing; isolated soft tissue injuries such as ligament, sprain and muscle strain are treated with rest, ice, compression bandage and elevation (RICE THERAPY) with or without immobilization.
Wound Exploration & Debridement
  • Under regional block, wound area is cleaned, explored for removal of any foreign material (if present).
  • Avoid tourniquet in crush injuries.
  • Be conservative in debridement of hand Injuries (Excise only the dead skin).
  • Injection injuries e.g. of oil, grease, hydraulic fluid, or paint under pressure are very demanding so immediate decompression is necessary.
  • Partial thickness burns are cleaned covered with non-stick dressing.
  • Immobilise in Boxers Gloves position.
  • ELEVATION of limb
Indications for Replantation/Revascularization:
  • Traumatic amputations of:
  • Thumb.
  • Multiple digits at transmetacarpal level.
  • Wrist.
  • Forearm.
  • At any level in a child.
Controversial Indication
  • Replantation of amputation of proximal arm with minimal ischaemia should be decided by attending Plastic Surgery.
  • Replantation of amputation of single finger distal to Flexor Digitorum Superficialis should be decided by attending on call
Contra-Indications for Replantation;
  • Multiple level of amputation.
  • Severe crush injury to the part.
  • Degloving injury to the part.
  • Prolonged ischaemia time (12 hrs for fingers & 6 hrs for proximal limb amputations).
  • Associated life-threatening injuries.
For Replantation, take following measures:
  • Take specialized opinion earlier.
  • Clean proximal stump.
  • Apply compression dressing.
  • Avoid tourniquets.
  • Wrap amputated parts in moist gauze, place in bag and cool (but not freeze) by placing on ice.
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