Khizer Ghalib Postgraduate Resident LGH

y It is necessary to prevent infection.Introduction y The hand and fingers are the body parts most often injured in the workplace. . y The surgeon must personally appraise the injury to decide which primary procedures can be done safely and which secondary procedures may be necessary later. y Restoration of function is the goal of treatment. and promote primary healing. salvage injured parts.

and amount of food and liquid taken by the patient 6) Patient's age.HISTORY 1) Exact time of injury 2) First aid given. amount. by whom and where 3) Nature. . handedness. and general health status. time. occupation. and time of receiving any medication 4) Exact mechanism of injury 5) Nature.

if not controlled by elevation alone. . the hand should be elevated with the patient supine. manual or digital pressure. may be sufficient. y If bleeding is severe. applied to the wound through the dressing.FIRST AID y ATLS Protocol y Open wounds should be covered immediately with a sterile dressing to prevent further contamination.

y Elevation and A pneumatic tourniquet may be helpful to control bleeding with cuff inflated to 100 to 150 mm Hg greater than the systolic pressure.FIRST AID y Bleeding can be controlled quickly by removing an improperly applied venous tourniquet. . y Hemostats and ligatures should not be used to control bleeding in the emergency department because this may damage intact vessels and nerves.

physical examination is attempted to determine which deep structures are functioning . y Probing the wound usually is unnecessary. and nerves. .FIRST EXAMINATION y To estimate the size of the wound. y The viability of the skin and any gross positional deformity are noted. y Pain usually limits examination. y The wound is covered. attention is directed first to the circulation and skin and then to bones. y Assessment of each tissue should be orderly.which must be considered damaged until proved otherwise. determine the extent of skin loss and injury to the deep structures. tendons.

. the patient should be advised as to the extent of the injuries. tetanus prophylaxis. sedation. especially possibility of amputation. y Final decision is delayed until the second examination in y The patient's general medical condition is evaluated. y Before sedatives or narcotics. the surgeon should obtain some idea about the injury and procedures needed surgical suite. y Antibiotics. blood transfusions. and prognosis.FIRST EXAMINATION y From this first examination. general plan of treatment. and other measures as indicated.

Anesthesia y Depending on the patient's age and general condition. the interval since the last ingestion of food or drink. and whether a distant flap will be necessary. other injuries. the severity of the injury. we can use y A regional block or y General anesthesia .

. tourniquet should be used as briefly as possible.Tourniquet y Tourniquet is necessary for cleaning and inspection. elevation for 2 minutes is better than wrapping with an elastic bandage before inflation of the tourniquet. and for deep structure repair y If viability of an area of skin is questionable. y For large wound with fractures.

Nails and nail beds are cleansed and trimmed. sterile pad is placed over the major wound. y Hand is scrubbed with antiseptic soap and water to above the elbow. y Uninvolved skin surrounding the wound is shaved. y Wound is exposed . antiseptics are not used in the wound because of potential tissue toxicity.Cleansing and Draping of Hand y First aid dressing is removed.irrigated with normal saline y Usually. .

but complete excision of the edges of the wound usually is unnecessary in the hand. . y Ragged skin edges may be trimmed. y Small flaps and tags of devitalized fat and fascia seen floating in the solution may be removed y Nerve ends are not débrided. more easily seen under saline solution.Cleansing and Draping of Hand y Finger is placed in the wound to loosen hematomas or to palpate the bones y Depths of the wound should not be rubbed with a sponge or brush. are clamped and cauterized. y Small bleeding vessels .

and the hand is redraped . and drapes used are discarded. carefully searched for foreign materials y Cleaning should not be hurried and often may take half of the total operating time to prevent infection. y After cleaning.Cleansing and Draping of Hand y Wound is cleaned. y Primary healing without infection is necessary to limit the scar and to allow early reconstruction. if needed. gloves. all instruments.

y The tissues in the depths of the wound. including exposed bones. and nerves. are assessed in an orderly. anatomical manner to avoid error.Second Examination y Conclusions drawn from the first examination may be wrong. tendons. vessels. so suspected tendon and nerve injury may be confirmed by direct inspection. . y Evaluating the skin damage is most important because primary wound closure depends on skin viability.

ORDER OF TISSUE REPAIR 1. Bone 3. Artery 2. Nerve . Tendon 4.

ligation remains a satisfactory option. repair of the injured artery is preferable.ARTERIAL INJURIES y In a young person if only one artery is injured without nerve injury. especially with nerve injury. repair of both arteries should be y Injuries to palmar arterial arch and digital arteries require exploration and micro-vascular repair if circulatory impairment threatens digital viability. performed y If both arteries are transected. . y In younger and older patients with inadequate circulation through the intact artery.

y Misjudgment may lead to delayed healing as a result of hematoma. which may require reopening of wound for drainage or additional débridement. edema.CONSIDERATIONS FOR SKIN CLOSURE y Primary skin closure can be done in all sharply incised. clean wounds. y Wounds not to be closed primarily. y The purpose of primary skin closure is y to obtain early healing and y to prevent infection. and excessive scar production. granulation tissue. include y Severely Crushed and y Highly contaminated . or infection. swelling.

suture of tendon or nerve. nerve. y An analysis of the five tissues is helpful in making the decision to amputate. it is wise to delay it if parts of the finger may be useful later in a reconstructive procedure. amputation should be strongly considered. or closure of joint. such as grafting of skin.CONSIDERATIONS FOR AMPUTATION y Only absolute indication for a primary amputation is Irreversible loss of blood supply to the part y Even if amputation is indicated. y In children. tendon. and joint) If three or more of these five areas require special procedures. amputation rarely is indicated unless the part is nonviable and cannot be made viable by microvascular techniques. bony fixation. . bone. (skin.

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