医学精品课件：05.Hand injury for students.ppt

1、HAND INJURYXiangjun ChengDepartment of Orthopedics The Second Affiliated Hospital of CQMUIntroduction of Hand The most complex and versatile structure in the human body 27 bones more than 30 muscles a vast web of ligaments and tendons Complicated vascular and nervous systemHand Positions Resting pos

2、ition of hand The position in which the forearm is midway between pronation and supination,the wrist is at 10 to 15 dorsiflexion,and the phalanges are slightly flexed.The thumb is in partial opposition and forward.Functional position of hand Consists of dorsiflexing both the wrist between 20 and 35

3、and the proximal interphalangeal joints between 45 and 60.The thumb is abducted and in opposition and alignment with the pads of the fingers.Hand PositionsResting position of handThis position would be changed if some structures (e.g.tendons or nerves)damagedFunctional position of handFacilitate loc

4、omotion of hand (e.g.grasp,making a fist)for manipulative tasksCauses of hand injury stab Penetrating trauma Blunt trauma:injury by club,injury by falling Crushing injury Firearm wound:bullet wound,explosion injuryVarious kinds of hand injuryVarious kinds of hand injuryPrinciples in treatments to ha

5、nd injuryhaemostasisContamination abatementStep 1Comprehensive and careful examination of woundsStep 2Time of dbridement Reparation of all structures in the primary stage including closure of woundsStep 3Correct postoperative careEarly rehabilitative exercisesStep 4Section 1 Injury to skin of hand O

6、pen hand injuryCareful history taking and physical examination1 location and character2 estimate skin defect3 judgement of skin vitalityHow to predict the skin vitalitySection 1 Injury to skin of hand Color and temperature of kineDigital pressure capillary reactionShape and size of the damaged skinR

7、eversed or antegrade avulsion Bleeding from skin edge Section 1 Injury to skin of hand Section 1 Injury to skin of hand Treatment of skin injury of handAvulsion injury of skinComplicated techniques and poor prognosisSkin defect of dorsum manusSplit-thickness autograftsFull-thickness autografts Diffe

8、rent kinds of skin flapsSimple woundDirect closureIf a large skin defect exists,various kinds of skin grafts or flaps may be involvedSection 1 Injury to skin of hand Common-used skin grafts or flapsCommon-used skin grafts or flapsSection 1 Injury to skin of hand Section 1 Injury to skin of hand Comm

9、on-used skin grafts or flapsSection 1 Injury to skin of hand Common-used skin grafts or flapsSection 2 Injury to tendon of the hand Movement of the muscles of the hand and arm are transmitted into finger and wrist motion by the tendonsStrong,compact units that glide within their individual compartme

10、ntsPassive motion of the joint still existsBoth active and passive motion are limited went joint disorderPatients are unable to actively move a joint,injury of tendon should be suspectedSection 2 Injury to tendon of the hand Physical examination Extensor tendon Flexor digitorum superficialis tendon

11、Flexor digitorum profundus tendonChanges of resting position of hand Extensor tendon Flexor digitorum superficialis tendon Flexor digitorum profundus tendonActive movement of handSection 2 Injury to tendon of the hand Rest positionActive movementSection 2 Injury to tendon of the hand Several specifi

12、c deformitiesMallet fingerSection 2 Injury to tendon of the hand Swan-neck deformitySection 2 Injury to tendon of the hand Buttonhole deformitySection 2 Injury to tendon of the hand Most of the tendon disruptions should be processed surgicallyThe state of the wound and the complexity of the injury a

13、re the principal issues the hand surgeon must weigh in choosing between a primary or secondary tenorrhaphyTenorrhaphy must be done without surface trauma along the tendon or its bedEnd to end or by weaving one with the other using nylon or wire suturesTendons should be anchored to bone （tendon inser

14、tion）Fixation of the hand in corresponding position for 3-4 weeks and the following functional exercisesTreatmentSection 2 Injury to tendon of the hand Section 2 Injury to tendon of the hand Section 3 Vascular and neural injury of the handVascular anatomyVascular injury of the handSection 3 Vascular

15、 and neural injury of the handVascular injury of the handHow to estimate the blood vessels during hand trauma Visual inspection:skin color,finger pulp shape,wound Palpation:skin temperature,wrist pulse,local edema Special test:capillary flow test On most conditions,theres no need to repair the vesse

16、ls of hand Single ulnar artery or radial artery should be reconstructed Both ulnar and radial artery injury was an emergency situation,and artery anastomosis should be conducted as quickly as possibleTreatmentSection 3 Vascular and neural injury of the handNeural injury of the handAnatomy of the ner

17、ve on handSection 3 Vascular and neural injury of the handNeural injury of the handAnatomy of the nerve on handSection 3 Vascular and neural injury of the handNeural injury of the handClinical manifestationRadial nerve:sensory loss of the corresponding areaMedian nerve:problems with opposition of th

18、e thumb and grip of the finger,and the sensory loss to the radial four digitsUlnar nerve:dysfunction of the intrinsic muscles,clawing of the ulnar two digits,weakness in gripping a key,sensory loss on the ulnar side of the handSection 3 Vascular and neural injury of the handNeural injury of the hand

19、Section 3 Vascular and neural injury of the handNeural injury of the handTreatmentObvious and complete disruption of the nerve is treated best by early surgical exploration and repairIncomplete lesion or questionable disruption of nerve integrity is best treated with close observation,splinting to p

20、revent contractures,and surgical exploration if no recovery occursSegmental loss of nerves requires nerve graftsPrimary repair much better than grafts or delayed repairsArthrodesis and tendon transferNO TENSIONSection 3 Vascular and neural injury of the handNeural injury of the handSECTION 4 SKELETA

21、L INJURY OF THE HANDCarpals,metacarpus,phalanges,interphalangeal joint,metacarpophalangeal joint,carpometacarpal jointSection 4 Skeletal injury of the handAnatomy of the bones and jointsSection 4 Skeletal injury of the handIntroductionClinical manisfectationPain,swelling,bruiseSpecific sign of fract

22、ure:deformity,abnormal movement,bone rubbingAssistant examinationX-ray,CTTreatmentEarlier correct therapyChange open fracture to a closed oneShort time fixation (3-4 weeks)Exercise as sooner as the patients can (rehabilitation)Section 4 Skeletal injury of the handSection 4 Skeletal injury of the han

23、dScaphoid fractureFall on the outstretched palm,severe hyperextension and slight radial deviation of the wristSwelling of the wrist,tenderness on the snuffbox,both passive and active movement are limitedX-ray,CT,MRIOften failed to diagnose,or delayed Short-arm or long-arm thumb spica cast for 12 wee

24、ksPercutaneous fixation,open reduction and Herbert screw insertionA wrist sprain that is sufficiently severe to A wrist sprain that is sufficiently severe to require radiographic examination initially require radiographic examination initially should be treated as a possible fracture of should be tr

25、eated as a possible fracture of the scaphoidthe scaphoidSection 4 Skeletal injury of the handScaphoid fractureSection 4 Skeletal injury of the handScaphoid fractureSection 4 Skeletal injury of the handmetacarpal fracture and phalangeal fractureDirect or indirect forcesTransverse,oblique,or spiral fr

26、actures are commonSplint,cast,K-wire,screw,plate,and other fixationSection 4 Skeletal injury of the handBennett fractureIntra-articular fracture of the base of the thumb metacarpal bone with subluxation of the metacarpal leaving a volar pyramidal shaped fragment attached to the trapeziumMetacarpal s

27、haft get a radial and volar displacement Reduction by traction is easy but is difficult to maintainClosed pinningOpen reduction Section 4 Skeletal injury of the handBennett fractureSection 4 Skeletal injury of the handMetacarpal neck fractureDirect forces,e.g.boxingMost are manipulatedSection 4 Skel

28、etal injury of the handAnterior dislocation of the lunateThe most common carpal dislocationOn a lateral radiographic view of the normal wrist,the half-moonshaped profile of the lunate articulates with the cup of the distal radius proximally and with the rounded proximal capitate distallyOn an antero

29、posterior view,the normal rectangular profile of the lunate when dislocated becomes triangular because of its tilt An anteriorly dislocated lunate can cause acute compression of the median nerve Section 4 Skeletal injury of the handAnterior dislocation of the lunateImmediately reductionWrist cast for 4-6 weeksOperation often needed for old dislocationTHANK YOU FOR THE ATTENTION