Page 1148 - TNFlipTest

PL26 Plastic Surgery
Hand Toronto Notes 2019
Amputations
Hand or Finger
• emergencymanagement:injuredpatientandamputatedpartrequiresattention
■ patient:x-rays(stumpandamputatedpart),NPO,cleanwoundandirrigatewithNS,dressstump
with nonadherent dressing, cover with dry sterile dressing, tetanus and antibiotic prophylaxis
(cephalosporin/erythromycin)
■ amputatedpart:x-rays,gentlyirrigatewithRL,wrapamputatedpartinaNS/RLsoakedsterile
gauze and place inside waterproof plastic bag, place in a container, then place container on ice • indicationsforreplantation
■ age:childrenoftenbetterresultsthanadults
■ level of injury: thumb and multiple digit amputations are higher priority; multiple level amputation
is a contraindication to replant
■ natureofinjury:cleancutinjurieshavegreatersuccess;avulsionandcrushinjuriesarerelative
contraindications to replant
• ifreplantcontraindicated,managestumpwithrevisionamputation
■ involves debriding stump of wound, trimming back the bone and nerve endings, and gently closing the skin
■ commonly done in the ER under digital block
Tendons
Common Extensor Tendon Deformities
Table 22. Extensor Tendon Deformities
Injury
Mallet Finger
Boutonnière Deformity
Swan Neck Deformity
Definition Zone
DIP flexed with loss 1 of active extension
PIP flexed, DIP 3 hyperextended
PIP hyperextended, 1,3 DIP flexed
Etiology/Clinical Features
There are bony and non-bony mallets Bony: Fracture of distal phalanx distal to tendon insertion
Non-bony: Forced flexion of the extended DIP leading to extensor tendon rupture at DIP (e.g. sudden blow to tip of the finger)
Injury or disease affecting the extensor tendon insertion into the dorsal base of the middle phalanx
Associated with RA or trauma (laceration, volar dislocation, acute forceful flexion of PIP)
Trauma (PIP volar plate injury) Associated with RA and old, untreated mallet deformity
Splint to prevent PIP hyperextension or DIP flexion
Treatment
Splint DIP in extension for
6 wk, followed by 2 wk of night splinting; if inadequate improvement after 6 wk, check splinting routine and recommend 4 more wk of continuous splinting
Splint PIP in extension and allow active DIP motion
Corrective procedures involve tendon rebalancing or arthrodesis/arthroplasty
DIP flexion
PIP hyperextension
PIP DIP
Zone 1 Zone 2
Zone 3 Zone 4
Zone 5 Zone 6
ABC
© Jackie Robers
Zone 7 Zone 8
Figure 24. Zone of extensor tendon injury
(odd numbered zones fall over a joint)
Figure 23. Extensor tendon deformities: (A) Mallet finger deformity (B) Boutonnière deformity (C) Swan neck deformity
De Quervain’s Tenosynovitis
• definition:tenosynovitisisinflammationofthetendonand/oritssheath.MostcommonisDe Quervain’s tenosynovitis (inflammation of the extensor tendons in the 1st dorsal compartment [APL and EPB])
• clinicalfeatures
■ +ve Finkelstein’s test (pain over the radial styloid induced by making fist, with thumb in palm, and
ulnar deviation of wrist)
■ pain localized to the 1st extensor compartment
■ tenderness and crepitation over radial styloid may be present
■ differentiate from CMC joint arthritis (CMC joint arthritis will have a positive grind test, whereby
crepitus and pain are elicited by axial pressure to the thumb)
© Jackie Robers | Erina He 2016