Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Traumatology and orthopaedics
Acute Trauma Management
Trauma in perspective
Principles of Primary Trauma Care
Six phases of Primary Trauma Care
Procedures
Orthopaedic Techniques
Traction
Casts and Splints
Application of external fixation
Diagnostic imaging
Physical therapy
Crania burr holes
Orthopaedic Trauma
Upper extremity injuries
The hand
Fractures of the pelvis and hip
Injuries of the lower extremity
Spine injuries
Fractures in children
Amputations
Complications
War related trauma
General Orthopaedics
Congenital and developmental problems
Bone tumours
Infection
Degenerative conditions
The Hand
 



LACERATIONS

Evaluation

:: Treat open injuries of the hand promptly. Perform a local examination to check circulation, sensation and motor function.
:: Gently examine the wound using aseptic technique to determine if it is clean or contaminated. A contaminated wound contains foreign material and crushed or dead tissue.


Treatment

1 Debride and lavage all wounds in the operating room or emergency area. If a local anaesthetic is needed, use 1% lidocaine without epinephrine.
2 Administer tetanus toxoid and antibiotics. Obtain X-rays to check underlying bones and joints.
3 Stop bleeding by compression with sterile gauze. If necessary, extend the wound, being careful not to cross skin creases in the palm or digits. Remove all foreign material and devitalized tissue, but do not excise any skin unless it is dead.
4 If the wound is clean, repair extensor tendons but not flexor tendons or nerves.
5 Close a clean wound over a drain using interrupted sutures if there is no tension on the skin. If the wound is contaminated, delay closure until after a second debridement. Wounds less than 1 cm square will granulate spontaneously. Use skin grafts for larger wounds, which will not close without skin tension.
6 Cover the hand with sterile gauze and a compression dressing (Figure 18.35).
Figure 18.35
Figure 18.35
7 Apply a plaster splint to hold the wrist in 20 degrees of extension, with the metacarpophalangeal joints in 90 degrees of flexion and the interphalangeal joints in full extension. Keep the fingertips exposed unless they are injured.
8 To control oedema, elevate the limb for the first week, either by attachment to an overhead frame or by the use of a triangular sling (Figure 18.36).
Figure 18.36
Figure 18.36
9 Begin active exercises as soon as possible and inspect the wound in 2–3 days to remove drains.


Nail bed injuries

:: Subungual haematoma causes severe pain resulting from a collection of blood deep under the nail. This can be seen as a dark red to black collection beneath the nail. To relieve pain, make one or two small holes in the nail with a hot safety pin or the tip of sterile number 11 scalpel blade.
:: If not repaired, lacerations of the nail bed may result in lasting nail deformity. Remove the nail and, after debridement and lavage, repair the laceration using fine suture. If possible, replace the nail over the sutured laceration until it heals and a new nail has begun to grow.


FRACTURES AND DISLOCATIONS

Fracture dislocation of the first carpometacarpal joint (Bennett’s fracture)

This is an oblique fracture of the base of the thumb metacarpal involving the first carpometacarpal joint (Figure 18.37).

Figure 18.37
Figure 18.37
1 Reduce the fracture with longitudinal traction to the thumb held in the abducted position.
2 Apply lateral pressure to the base of the metacarpal to reduce the fracture and the dislocation (Figure 18.38).
Figure 18.38
Figure 18.38
3 Maintain the reduction with a thumb spica splint.


Metacarpal fractures

Metacarpal fractures commonly occur at the base, midshaft and neck. Most fractures are stable and can be treated with closed manipulation and plaster immobilization. Rotation is the most important deformity to correct. If it persists, the digits will cross with flexion, impairing general function of the hand.

:: Treat with a short arm cast or splint with the wrist in extension and three point moulding about the fracture. When treating unstable fractures, extend the cast to include the involved digit or tape the digit to an adjacent digit to provide rotational stability.
:: Healing time is 4–6 weeks.


Phalanges

:: Treat non-displaced, stable fractures by taping the fractured digit to the adjacent uninjured digit (buddy tape, Figure 18.39), or with a simple dorsal splint
Figure 18.39
Figure 18.39
:: Reduce displaced fractures with traction and direct pressure to correct the deformity. Apply a short arm cast with an attached metal splint extending under or over the digit.


Mallet finger

Mallet finger results from a tear of the long extensor tendon at its insertion into the distal phalanx. It may be associated with an avulsion fracture of the dorsal lip of the distal phalanx (Figure 18.40).

Figure 18.40
Figure 18.40


Treat by splinting the distal phalanx in slight hyperextension (Figure 18.41). Maintain continuous extension for 6–8 weeks.

Figure 18.41
Figure 18.41



Top of Page

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  
  Kep Points  
Treat lacerations promptly with careful evaluation, debridement and lavage


Close wounds only when clean, using suture, spontaneous healing or skin grafts



 
After injury, elevate the hand to control swelling and begin motion early


 
Nail bed injuries require special treatment.