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HAND

Hand Anatomy

??The wrist is a bio-mechanically complex joint allowing the wrist to move in extension (up), flexion (down), radial deviation (towards the thumb), ulnar deviation (towards the small finger) and minimal degrees of rotation. view 

Hand Contusion

Trauma is the term used to describe injury. Trauma is classified by its severity depending on the amount of force used to cause the injury. view 

Hand Fractures

A fracture is a break in the bone. Fractures in the hand are some of the most frequent in the upper extremity. view 

Hand Dislocations

Dislocations of the hand are injuries frequently associated with high energy trauma like a fall from a height, a motor vehicle collision or a sporting event. view 

Hand Open Wounds

Open wounds at the hand imply the disruption of the skin with exposure of deeper structures. view 

Hand Tendon Injuries

Tendons are the continuation of muscles which transmit the force of muscles to the bone it attaches to around a joint to generate motion. view

Nerve and Vessel Injury

Nerves are cables that transmit impulses from the brain and spinal cord that give specific orders to the various body parts. view

Hand Compartment Syndrome

Compartment syndrome in all extremities is an orthopedic emergency. The hand muscles are covered and divided by groups into compartments by a well defined, unyielding envelope called the deep fascia. view

Hand Amputations

An amputation is the severing of a body part. Amputations are classified as partial and complete and if the amputation was a clean cut, a crushing amputation or an avulsion amputation where the amputated limb is pulled right off of the body. view

Hand Arthritis

Joint arthritis occurs when the protective cartilage layer wears away. The joint then becomes more painful and loses motion. view

Hand Infections

Infections to the hand are common occurrences because our need to use our hands for all activities. view

Hand Mass/Tumors

The most frequent swelling or masses found at the hand and wrist level are ganglion cysts. view

HAND AMPUTATIONS

Pathology

An amputation is the severing of a body part. Amputations are classified as partial and complete and if the amputation was a clean cut, a crushing amputation or an avulsion amputation where the amputated limb is pulled right off of the body. The avulsion amputation has the worse prognosis with the zone of injury being very wide. When an amputation occurs from the mid-palm to the level of the shoulder, it is a true emergency and must be replanted no more than 4-6 with warm ischemia but can be extended to 8 hours if it is cold ischemia (when the part is placed in an ice bath) after injury because the oxygen demands and metabolism of the muscles is high causing tissue death or necrosis if the blood supply is not restored within this time period. The necrotic changes that have taken place in the amputated part lacking oxygen will cause a dumping of this necrotic material into the bloodstream and cause a systemic collapse called Disseminated Intravascular Coagulation (DIC) that risks the persons’ life who is undergoing a replantation. If this occurs, the amputated part must be removed.

When amputation occurs, the amputated part must be immediately wrapped in gauze moistened in saline and placed in ice slush made by crushing ice and placed in zip lock plastic bag and then put in a cooler while transporting it to ROC for possible replantation. Amputations from mid-palm to fingers have more time to be replanted because fewer muscles are found in this area. Time to replantation of fingers can be successfully done at 15 hours post amputation for this same reason.

Treatment

The treatment of an amputation starts immediately after amputation. That is placing the amputated part in cold ice slush and transporting it to a replantation facility like ROC. Upon arriving in an emergency facility, the patient is prepared for surgery while the amputated part is taken to the operating room, cleaned and dissected out under a microscope, preparing it for replantation. Replantation can be successful with amputations beginning at the most distal joint (DIP joint) and more proximal amputations towards the shoulder. That is because the arteries and veins become too small to repair if it is beyond the DIP joint. However, in selected cases, after discussing the case with the patient (parents), your surgeon at ROC may decide to attempt replantation of a tip with a variant of the technique. This is especially true and important for fingertip amputations in the pediatric population where the tip can be sutured back as a composite graft. Your surgeons at ROC have long experience with many cases of children that have had their amputated fingertips successfully reattached. During a replantation, the bone is fixed first, followed by the repair of the tendons, then the nerve, then whether you fix the arteries or veins first is surgeons choice since some prefer to fix the vein first to prevent excessive bleeding from the veins and others prefer fixing the arteries first to more easily visualize the veins. The skin is then carefully closed and it may require the use of skin grafts to avoid tension on the closure. The extremity is then placed in a long arm well padded splint to protect the replanted part. Regularly the patient is admitted to the hospital for approximately 5 days and is kept in a warm, calm, controlled environment with blood thinners to keep the vessels flow going.

Replantations need of a comprehensive, well structured hand therapy program to start motion as early as possible and prevent complications from stiffness and adhesions on the replanted part or adjacent non-injured digits. This is a challenging task for the therapist because they have to find the right balance between motion, effort and protection of all repaired structures (fracture fixation, skin grafts, tendon, nerve and vessel repairs). The obvious consequences of inappropriate therapy are failure to achieve best possible function, rupture of repairs or in the worst case scenario, loss of replanted parts. This is why you must attend to a qualified and experienced Hand Therapy Facility like ROC- Therapy to complement the efforts of a replant surgery.

Amputations that are from the forearm to the shoulder are more successful if it occurs in patients younger than 15 years of age, is a clean cut and the part is brought for amputation immediately. Partial amputations with skin still attached should be left attached since valuable blood supply may still be supplied through the retained tissue. If an amputation is an avulsion which is a pulling injury, or a severe crush injury, has severe contamination, extensive tissue damage, double level of injury, the likelihood of a successful replantation is significantly less. Other important factors like time from injury, level of amputation, heart disease, diabetes, renal disease, hypertension, peripheral vascular disease, advanced age and smoking habit amongst others, will affect the prognosis and final decision to attempt a replantation. Regardless of the type of amputation, bring in the amputated part immediately for the surgeon to assess the replantation likelihood of success.