1. HAND INJURIES
DR. UTKARSH SHAHI

3. NERVE
INJURIES
Palmar digital nerves
Supplies the pulp of finger

4. NERVE INJURY MODE TREATMENT
MEDIAN NERVE • The median nerve may be cut cleanly
across at the wrist or palm by sharp
objects or by falls through windows.
• These injuries are ideal for immediate repair; i.e. within 24
hours of injury.
• The results are generally good, particularly in children
• But complete recovery never occurs.
• The flexor tendons are usually injured at the same time and
accurate repair of all the structures involved can be very
difficult.
ULNAR NERVE • The ulnar nerve can also be damaged in
this way but it lies deeper than the
median nerve and is protected by the
tendon of flexor carpi ulnaris.
• As with the median nerve, the results of repair are
acceptable but never perfect.
PALMAR DIGITAL
NERVES
• The palmar digital nerves are very
vulnerable and are cut if the patient
grips a blade or a sharp object.
• The digital artery is usually damaged at
the same time.
• Because the volar digital nerve supplies
the pulp of the finger, injuries to it can
seriously impair function.
• The cutaneous nerves on the dorsum of the finger, distal to
the middle of the middle phalanx, are too small to repair.
• On the palmar surface the nerve is large enough to repair
as far distally as the distal interphalangeal joint.
• Lesions proximal to these points should be repaired under
magnification.

5. CRUSHED NERVES &
DIRTY WOUNDS
Contaminated or
untidy nerve lesions
are not suitable for
immediate repair..

6. CRUSHED NERVES & DIRTY WOUNDS
The ends of the nerve can
be tagged with a marking
suture and the nerve
repaired when the wound
has healed.
The end of the
nerve will then
have a firm fibrous
cap of epineurium,
which must be
removed before it
can be repaired.
The nerve must also be
mobilized proximally and
distally to give extra
length.

7. TENDON
INJURIES

8. FLEXOR
TENDON
ZONES

9. ZONE ANATOMICAL DETAILS TREATMENT
I Injuries distal to the distal
interphalangeal joint (i.e.
outside the tendon sheath)
• Zone I lesions can be treated by:
• Tendon advancement
• Arthrodesis of the distal interphalangeal joint
• The cut end of the tendon can be advanced and reinserted on the distal phalanx.
• This may cause a slight flexion deformity.
• In the thumb the advancement can be done in the forearm because the flexor
pollicis longus has no connection with other flexors and its tendon can be separated
from the muscle belly in the forearm and moved distally.
• The results of surgery are better in the thumb than the fingers.
• Early movement, active or passive, is important after any tendon repair and several
devices are available to encourage this.
II Injuries distal to distal skin
crease but proximal to
distal interphalangeal joint
• Management of flexor injuries in the fingers depends on the tendons involved and
the site of injury.
• The first step is to decide which tendon has been damaged.
• Profundus and superficialis action can be distinguished by asking the patient to flex
the distal phalanx with the middle phalanx held still.
• Only flexor profundus will do this because superficialis does not extend beyond
the middle phalanx.
• To assess superficialis, hold all the fingers down except the one that is to be
tested and ask the patient to flex that finger.
• If the finger flexes at the proximal interphalangeal joint, superficialis is
intact.

10. ZONE ANATOMICAL DETAILS TREATMENT
II Division of Flexor Digitorum
Superficialis (FDS) alone
• If superficialis is divided alone it is best to excise the redundant portion of its tendon
and rely on flexor profundus for finger flexion
• Thus avoiding the problems of adhesions and stiffness.
• Alternatively, the lesion can be ignored.
Division of Flexor Digitorum
Superficialis (FDS) & Flexor
Digitorum Profundus (FDP)
• If the tendons are cut opposite the proximal or middle phalanx they can be treated
• Either by meticulous primary repair by an experienced surgeon
• Or by replacing the tendon with an autograft of another tendon.
• Such as palmaris longus or plantaris.
• If both tendons are cut, both should be repaired.
Division of Flexor Digitorum
Profundus (FDP) alone
• If the tendon is divided within 1 cm of its insertion the tendon can be pulled up, or
‘advanced’, and the cut end attached to the distal phalanx.
III Injury in the palm • Division of the flexor tendons in the palm is less serious than division in the fingers
because the repair can be done outside the fibrous or synovial sheaths.
• The tendons should be repaired meticulously by an experienced hand surgeon and
early mobilization instituted.

11. ZONE ANATOMICAL DETAILS TREATMENT
IV Injury around carpal tunnel • Eleven flexor tendons cross the volar aspect of the wrist.
• Flexor digitorum superficialis (4)
• Flexor digitorum profundus (4)
• Flexor pollicis longus
• Flexor carpi ulnaris
• Flexor carpi radialis
• If all these are divided, there will be 22 cut tendon ends.
• If the median nerve is divided as well, there will be 24 structures, which must be
carefully identified.
• If each pair is joined there will be 12 suture lines very close together.
• However carefully repaired, the tendons and nerves may stick together and form a
solid mass which restricts movement at the wrist.
• The problem can be simplified by discarding those tendons that are not absolutely
necessary.
• The flexor superficialis, for example, can be sacrificed if flexor profundus is
working.
• Finger flexion will still be full and the risk of adhesions between superficialis
and profundus outweigh the improvement of function that might be obtained
by repairing both.
V Injuries in the forearm • Injuries in the forearm lie outside any sheath and can be accurately repaired more
easily than elsewhere.
• The tendon ends are accurately identified and repaired & early mobilization begun.

12. SPECIFIC INJURY SCENARIO TREATMENT
Contaminated wound & Crushing
injuries
• If the wound is untidy and dirty it must be debrided and all dead tissue removed.
• If the wound is untidy but clean it is sometimes better to excise the tendon and
replace it with a Silastic rod, which can itself be replaced with a graft when the
wound has healed.
• If the wound is contaminated, a clean and well healed wound must be obtained
before definitive treatment is undertaken.
Aftercare • The hand should be mobilized actively and passively as soon as pain and swelling
permit.

13. EXTENSOR TENDONS

14. EXTENSOR TENDON INJURY
Because the extensor tendons
only have a synovial sheath
where they cross the wrist,
the problems encountered in
repairing flexor tendons in the
fingers do not arise.
The tendons are
• Easily identified
• Repair is straightforward and
• The fingers can be mobilized after 3
or 4 weeks.
If the tendons are divided on
the dorsum of the hand they
cannot contract for more than
a few millimetres because
they are restricted by linking
fibrous bands.
Tendons divided on the
dorsum of the hand should be
repaired and the fingers
splinted in extension for 3
weeks.
Even without repair some
extensor function will
eventually return

15. MALLET FINGER
Violent flexion injuries to, or lacerations across the
back of, the Distal interphalangeal joint can avulse
or divide the insertion of the extensor digitorum
longus at the base of the distal phalanx.
Untreated, the lesion causes the distal phalanx to
droop and leaves a ‘mallet’ finger deformity.
The condition is inconvenient, but function
improves without treatment and it is exceptional
for the patient to be seriously troubled by the
injury 12 months later

16. MALLET FINGER
Although the results are acceptable without
treatment, Splintage can produce a better result.
The finger should be immobilized for 6 weeks in
a mallet finger splint which holds the distal
interphalangeal joint hyperextended but allows
movement at the proximal inter phalangeal joint
Some loss of active extension may persist.

17. BOUTONNIERE LESION
The central slip of the extensor expansion
can be detached from its insertion at the
base of the middle phalanx by a cut or by
violent muscle contraction.
This allows the two lateral slips to fall
sideways and the proximal interphalangeal
joint to protrude between the two, which
produces a characteristic deformity and may
impair function

18. BOUTONNIERE LESION
The lesion should be splinted with
the finger straight, but the results
are imperfect.
If the final disability justifies it,
the two slips can be
approximated to restore
extension but flexion may be lost.

19. BLOOD VESSEL
INJURY IN THE PALM
• The deep palmar arch can be
cut by penetrating injuries
and causes serious bleeding.
• Bleeding must be stopped to
avoid a large palmar
hematoma and skin necrosis.

20. BLOOD VESSEL
INJURIES AT
WRIST
Damage to the radial or ulnar arteries at the
wrist causes severe arterial bleeding, which can
be controlled by firm pressure and elevation.
If both radial and ulnar arteries are ligated,
ischaemia of the hand may result, and at least
one, preferably the radial, should remain intact.
If both treatment arteries are damaged, arterial
repair is required.

22. CRUSHING INJURY
Fingers can be crushed so hard that the skin bursts.
These injuries must be treated by elevation of the arm
and hand.
The wounds must never be sutured.
Although it is technically possible to close the wounds
soon after injury, the sutures prevent the soft tissues
from swelling and a stiff or dead digit will follow.

23. CRUSHING INJURY
The wound should be cleaned,
lightly dressed and the hand
elevated.
After 48 h the swelling will begin to
subside and the skin edges will come
together on their own.
Delayed primary suture is
sometimes needed.

24. DEGLOVING INJURY
If the hand is caught in machinery,
the skin of the hand and fingers can
be peeled off like a glove.
This is a serious lesion and cannot be
treated by rolling the skin back into
place.
The lesion can be caused by a ring.

25. DEGLOVING INJURY
The skin defect must be grafted by an
experienced surgeon,
• Either by removing the subcutaneous fat from the
degloved skin and applying it as a free graft
• Or by taking a graft from elsewhere.
If paratenon is stripped from the tendons, flap
cover is required.
Alternatively, the ring finger can be amputated
and its skin used to cover the defect.

26. GRINDSTONE INJURY
Accidental contact with a grindstone removes
skin, subcutaneous tissue and bone.
The wound is contaminated and the loss of
tissue can be irreparable.
Treatment depends on the lesion but, if the
knuckle is involved, arthrodesis or amputation
may be preferable to a protracted series of
reconstructive procedures.

27. INJECTION INJURY
Although rare, the injuries caused by high pressure injection devices such as
• High pressure water nozzles
• Paint sprays and
• Grease guns
These implements can force grease or water through the skin and into the subcutaneous
tissues without any opening in the skin itself.
The irritation in the soft tissues can lead to tissue necrosis and the integrity of the skin is
misleading.
The hand must be explored and all extraneous material removed.
If this is not done the ensuing inflammation, particularly if complicated by infection, may lead
to amputation.

28. SKIN INJURY
Skin incisions or lacerations that cross skin creases on the flexor aspect of joints may shorten when
they heal and form a tight fibrous contracture that holds the joint flexed.
While there is no choice in the position of a laceration, incisions used to repair tendons and nerves
must not cross skin creases transversely.
The wound should be carefully cleaned, but never use spirit to clean a wound on the hand.
The spirit will damage exposed nerve tissue and cause an intense inflammatory response in the
flexor tendon sheath that restricts flexor tendon movement.
Aqueous solutions of chlorhexidine or cetrimide are preferable and the detergent action of these
agents is an added advantage.
Once cleaned, the wound edges can be brought lightly together with fine sutures and the hand
elevated until swelling has subsided.

29. HUMAN BITES
Genuine human bites are uncommon away from the rugby
field.
Knuckles are often injured against teeth – a ‘fight bite’.
Injuries caused in this way often fail to heal and become badly
infected with a cocktail of exotic organisms.
The wound should be cleaned, excised and enlarged, and left
unsutured, and adequate antibiotics given.

30. FRACTURES &
DISLOCATIONS
The management of fractures in the hand, like
the management of fractures elsewhere.
It follows the principle that stable fractures
should be mobilized soon, whereas unstable
fractures should be stabilized and then
mobilized.
Early mobilization is even more important in
the hand than elsewhere.

31. FRACTURES &
DISLOCATIONS
Scaphoid fractures
Triquetral fracture
Carpal dislocation
Metacarpal fractures
Metacarpophalangeal dislocations
Phalangeal fractures
Phalangeal dislocations

32. FOOSH INJURY
(Falling on Outstretched hand)

33. Wrist joint

34. Wrist joint

35. DISTAL END RADIUS FRACTURES

36. ULNAR STYLOID FRACTURES

37. SCAPHOID FRACTURES

38. LUNATE FRACTURES

39. TRIQUETRAL FRACTURES

40. DISTAL END RADIUS FRACTURE
COLLES FRACTURE
SMITH’S
FRACTURE
CHAUFFEUR’S
FRACTURE
BARTON’S FRACTURE DIE PUNCH FRACTURE
Pathophysiology
Low energy, dorsally
displaced, extra-
articular fracture
caused by FOOSH
with hyperextension
at wrist
Low energy, volar
displaced, extra-
articular fracture
caused by FOOSH
with hyper flexion
at wrist
Radial Styloid
fracture usually
caused by sudden
and frequent
radial deviation
of wrist
High energy, dorsally
(Dorsal Barton) or Volar
(Volar Barton) displaced,
intra-articular fracture
caused by FOOSH with
hyperextension at wrist
High energy, impacted
fracture of distal end
radius causing
depression in the
articular surface of
Radius caused by direct
axial loading at wrist
Clinical
Presentation
Pain
Diner Fork Deformity
Pain
Volar
displacement
Volar Tilt
Pain in radial
deviation of Wrist
Pain
Restricted Joint Motion
Pain
Restricted Joint Motion
Treatment
Options
Colles Cast
External Fixation
ORIF/CRIF
Short Arm Cast
ORIF/CRIF
CRIF ORIF ORIF with bone grafting
Complications
Complex Regional Pain Syndrome (CRPS)
Compartment Syndrome
Radio-Ulnar Synostosis
Malunion and Non-union
Median/Ulnar Nerve Neuropathy
Muscle/Tendon Rupture

41. SMITH’S#

42. COLLES#
DINNERFORKDEFORMITY

43. BARTON’S#
CHAUFFEUR’S#

44. DIEPUNCH#

45. OTHER WRIST FRACTURES
ULNAR STYLOID
FRACTURE
SCAPHOID FRACTURE LUNATE FRACTURE TRIQUETRUM FRACTURE
Pathophysiology
Fracture usually
caused by sudden
ulnar deviation of
wrist
High energy fracture
caused by FOOSH with
hyperextension at wrist
High energy fracture caused
by FOOSH with
hyperextension at wrist
High energy fracture
caused by FOOSH with
hyperextension and ulnar
deviation at wrist
Clinical Presentation
Pain in ulnar deviation
of Wrist
Pain in anatomical snuff
box
Pain in resisted
pronation
Usually associated with peri-
lunate dislocation
Pain in wrist during
dorsiflexion
Usually associated with
Pisiform and/or Hamate
Fracture
Pain in wrist ulnar side
Treatment Options CRIF/ORIF
SCAPHOID CAST
CRIF/ORIF
CRIF/ORIF
SHORT ARM CAST
CRIF/ORIF
Complications TFCC Injury
Non-Union
SNAC Wrist
Wrist Instability Ulnar instability of Wrist
TFCC: Triangular Fibro-Cartilage Complex
SNAC: Scaphoid Non-union Advanced Collapse
ORIF: Open Reduction Internal Fixation
CRIF: Closed Reduction Internal Fixation

46. ULNARSTYLOID#
SCAPHOID FRACTURE

47. PERILUNATEDISLOCATION
LUNATE
FRACTURE

48. TRIQUETRAL#

51. HAND

52. HAND FRACTURES
DISTAL CARPAL FRACTURES
• HAMMATE FRACTURES
BASE OF THUMB FRACTURES
• INTRA-ARTICULAR FRACTURES
• BENNETT’S FRACTURE
• ROLANDO FRACTURE
• EXTRA-ARTICULAR FRACTURES
OTHER METACARPAL FRACTURES
• BOXER’S FRACTURE
PHALANGEAL FRACTURES

53. BASE OF THUMB FRACTURES
BENNETT’S FRACTURE ROLANDO’S FRACTURE
EXTRA – ARTICULAR
FRACTURES
Pathophysiology
Oblique intra-articular metacarpal
fracture dislocation, caused by
an axial force directed against the
partially flexed metacarpal. E.g.
when a person punches a hard
object. It can also occur as a result of
a fall onto the thumb. E.g. fall from
bike.
A 3-part intra-articular fracture of the base
of the thumb metacarpal. These T- or Y-
shaped fracture patterns can occur either
in the frontal, or in the sagittal plane
The causative mechanism is axial overload
along the first metacarpal causing
compression failure of the joint surface.
Oblique or extra-articular
fracture of base of thumb
metacarpal. Typically caused
by the same mechanism of
injury as for Intra-articular
fractures.
Clinical Presentation Instability of the CMC joint of the thumb, accompanied by pain and weakness of the pinch grasp.
Treatment Options Thumb Spica/External Fixation/CRIF/ORIF
Complications Post-traumatic Arthritis Malunion
CMC: Carpometacarpal Joint
ORIF: Open Reduction Internal Fixation
CRIF: Closed Reduction Internal Fixation

54. HAND FRACTURES

55. GAMEKEEPER’S THUMB
• The medial collateral ligament of the
first metacarpophalangeal joint is easily
torn by any violent abduction injury.
• The lesion is called a gamekeeper’s or
poacher’s thumb because of the
method used to break the neck of
game, particularly rabbits.
• This story is not entirely accurate.
• The lesion is also caused by falls,
particularly on dry ski slopes, where the
hand may slide down the surface until
the thumb catches on an irregularity or
in a pole strap.

56. GAMEKEEPER’S
THUMB
• The ligament can be either torn
directly across or avulsed with a flake
of bone.
• Left untreated the thumb is unstable
and cannot resist the force on the
index finger in a pinch grip.
• Cast immobilization or surgical repair
of the lesion is often required but
there may be some residual
disability.

57. OTHER HAND FRACTURES
HAMATE FRACTURE BOXER’S FRACTURE PHALANGEAL FRACTURES
Pathophysiology
Could occur in either body or
hook. Main cause for these
lesions is a direct impact against a
hard surface with a clenched fist.
Transverse fracture of neck of 4th or 5th
Metacarpal, usually caused by the impact
of a clenched fist with a skull or a hard,
immovable object, such as a wall.
Intra-articular fracture of
Proximal/middle/distal Phalanx
Mechanism depends on age
• 10-29 years of age: sports is
most common
• 40-69 year of age:
machinery is most common
• >70 year of age: falls are most
common
Clinical Presentation
Pain in ulnar side of wrist.
May be associated with
Triquetrum/Pisiform/Base of 4th
and 5th Metacarpals
Pain, swelling and/or deformity
corresponding to the level of injury
Pain, swelling and/or deformity
corresponding to the level of
injury (single/ multiple)
Open fractures are common
Treatment Options
Cast Immobilization for
extra-articular
ORIF for Intra-articular fractures
Cast Immobilization for simple fractures
with minor angulation
ORIF for fractures with severe angulation
Buddy Strapping
ORIF/CRIF
Complications Stiffness/ Malunion Mal-union/ Deformity
Malunion/ Deformity/ Infection
Stiffness if Intra-articular
ORIF: Open Reduction Internal Fixation
CRIF: Closed Reduction Internal Fixation

60. STRAPPING

63. DO NOT FORGET
ABOUT
REHABILITATION
AFTER ANY HAND
INJURY

64. DETAILED READINGS FOR…..
NERVE INJURIES
OF HAND
FLEXOR TENDON
INJURIES WITH
ZONES
MALLET’S
FINGER
BOTOUNNAIRE’S
DEFIRMITY
GAMEKEEPER’S
THUMB
DEGLOVING
INJURY
GRINDSTONE
INJURY
SCAPHOID
FRACTURE
BENNETTE’S
FRACTURE
FIFTH
METACARPAL
FRACTURE