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INJURY OTHER THAN FRACTURE
HAND DISEASES, DAMAGE AND DEFORMITY
AMPUTATION
Amputations in the hand are commonly the result of a traumatic injury but may be the result of a planned operation to prevent the spread of serious disease.
Traumatically-amputated fingers and hand are replanted (reattached) by us regularly since 1991.
8 years old sustained an amputation of the arm in a road accident. The child reported to the hospital after 3 hours with the hand in a polythene bag! Within minutes the arm was in the operation theatre. In an overnight surgery the arm was successfully reattached. The boy is a grown-up married man and gainfully employed! This was done in 1996! First for the city of Pune.
The boy is a grown-up married man and gainfully employed! This was done in 1996! First for the city of Pune.
Picture taken 23 years after replantation of right upper arm.
Case No.2
Case No. 3
FINGER TIP
Finger tip is the part of the finger close to the nail before the adjacent joint of the finger.
Fingertip is the commonest injury seen in a hand surgery clinic.
Cause: It usually follows the finger getting jammed in the door or caught in a machine. The spectrum of fingertip injuries may be confined to just avulsion of the nail plate to amputation of the fingertip.
Nail is lost: If the nail is avulsed, it is necessary to thoroughly clean the part to eliminate all contamination, eliminate any possibility of infection and then to re position the nail. This step ensures that the new nail grow nicely.
Fingertip is amputed: The part may be reattached by microsurgery. On other occasions the fingertip is reconstructed. Ultimate aim is to provide length and cosmetically acceptable finger. This will require restoration and reconstruction of the skin over the finger. The skin may be imported from the same finger or adjacent finger or the palm. This is called flap surgery.
The flaps have various technical names, called:
- VY Plasty.
- Thenar flap.
- Cross finger flap.
- Composite grafting.
- Kite flap.
- Reverse flow flap… etc.
- Free flaps
Before Surgery After Surgery
Finger Wound Flap
When the skin is lost due to trauma or any other reason and the bone or tendon are exposed or the wound is deep with require a skin cover which has a blood supply. An island of skin which has its own blood supply is called a flap. Certain wounds depending on their location and depth may require flap surgery.
While a large number of wounds heal with the passage of time, others require a flap cover. This wound had exposed extensor tendon and was covered with a transposition flap.
The wound over the finger did not heal for a very long time and the tendon which extends the finger was also exposed. This was covered with the flap which was hitched from one location to another with an intact blood supply.
Before Treatment After Treatment
Flap
When the skin is lost due to trauma or any other reason and the bone or tendon are exposed or the wound is deep with require a skin cover which has a blood supply. An island of skin which has its own blood supply is called a flap.
This person was injured, sustained a large wound with the extensor tendons exposed. The wound was covered with a flap. The flap is called posterior interosseous artery (PIA) flap.
The rehabilitation is important to prevent stiff fingers. As one will appreciate, he regained full movements of the fingers with appropriate follow-up and dynamic splinting.
Before Treatment
After Treatment
Forearm slashed wrist
A sharp weapon or a glass edge can severe the tendons, nerve and the blood supply requiring urgent repair of all the structures. Sometimes, almost 12 tendons, 2 nerves and 2 arteries can get severed.
- Glass injury to the forearm.
- All 12 tendons which flex the fingers and the wrist are cut; two major nerves which provide sensation to the fingers are cut; 2 major arteries were cut.
- They were all repaired using fine microsurgical techniques.
- Over the next few weeks, the fingers were mobilized.
- Over the next few months, sensation started to recover as well.
Before Treatment After Treatment
GAMEKEEPER THUMB
It is an injury to the ligament of the thumb due to a fall with the load of the body transmitted to the thumb. This causes instability and difficulty in pinching activities.
Following a fall on the stretched out thumb, the person gets swelling and pain on the inner aspect of the centre of the thumb.
A special X-Ray called a stress view is obtained. To get a stress X-Ray view, the injured area is very gently deviated and stress to assess the extent of ligament injury. If the ligament is totally torn, the joint will open out abnormally and will be visible on the X-Ray.
This shows abnormal opening on the medial (inner) side of the thumb.
There may be a bony avulsion or purely ligament injury.
In the normal thumb, the ligament is deep and muscle is superficial. In this condition, the injury causes the ligament to come to lie more superficial to the muscle. This reversal of the location of these structures is called as Stener lesion. This requires surgery to correct the Stener lesion.
Special very tiny anchors may be required to fix the avulsion if bone is not of adequate size.
Before Surgery
Stress view showing abnormal opening of the joint. The straight arrow points at the opening. The curved arrow demonstrate the direction of the stress.
During
Anchors measuring 1.2mm are inserted to re-fix the torn ligament.
After Surgery
X-Ray immediately after surgery shows temporarily fixed wire in place, together with a very tiny anchor.
NERVE INJURY
Nerves are structures which connect hand to the brain. They provides sensation and control the movements of the muscles. When the nerves are cut a person may loose sensation to a certain part of the hand. Or function of a certain muscles may be lost depending on the location of the injury.
The nerves are extremely delicate structures.
- They have to be repaired very early for optimum recovery. With passage of time, the quality of recovery gets poorer and sub-optimal.
- The repair is done under magnification to match the cut fibers.
- The repair material is barely visible to naked eyes and measured in microns or repaired with a special glue.
- The repair is done without any tension at the repair site. With passage of time, the nerve retracts. This means an early repair is the good repair.
- If the injury is present for quite some time, the nerve will retract. In such a scenario, the gap in the nerve is bridged and grafted with another spare nerve harvested from some other part of the body.
- The nerve surgery is done when the overlying skin is healthy and of the normal quality.
Fall of a glass piece on the forearm of a six years old child. The site of profuse bleeding and shrieking of the child raised an alarm in the family and the neighbourhood. Sharp injury is generally suggestive of nerve injury, hence wound was explored. Sure enough, the Ulnar nerve was found severed.
The Ulnar nerve repaired under microscope.
FOR HAND INJURY, DEFORMITY, DISEASES AND PAIN IN HAND.
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