1、03/04/2014,Hand Injury,Department of Orthopedic SurgeryZhou Xiang, M.D.,03/04/2014,Learning outcomes,熟悉手外伤的诊断方法、周围神经损伤的病因和诊断。掌握手开放性损伤的治疗原则。,Contents,一、手外伤1.创口情况检查、诊断2.手部开放性损伤、骨折的处理原则3.肌腱与神经损伤的诊断与处理原则 二、断肢（指）再植1断肢（指）的分类及预后2断肢（指）的急救内容及注意事项3常温下一般再植时限,Anatomy,03/04/2014,Hand Injury,Mostly open injury Ma
2、y affect personality,03/04/2014,Skin Injury,03/04/2014,Tendon Injury,Flexor tendon Extensor tendon,03/04/2014,03/04/2014,Vessel Injury,Neurovascular bundles Contain digital artery, vein, and nerve Two bundles: one radial and the other ulnar Radial and Ulnar arteries join in 2 arches Superficial Palm
3、ar Arch: superficial to flexor tendon Located at base of first web space Deep Palmar Arch (deep to flexor tendons) Proximal to superficial arch by 1 cm,03/04/2014,Nerve Injury,Ulnar Nerve Motor Allows for power grip Innervates all hand intrinsic muscles except: Does not innervate two radial lumbrica
4、ls Does not innervate thenar muscles Sensation Ulnar 1.5 fingers (palmar) Course Passes with ulnar artery via Guyons Canal in wrist Test function Finger abduction against resistance Palpate belly of first dorsal interosseus muscle,03/04/2014,Nerve Injury,Median Nerve Motor Allows for fine control of
5、 pincer grasp Innervates thenar muscles and two radial lumbricals Sensation Radial 3.5 fingers, and their dorsal tips Cutaneous innervation Image Course Passes via carpal tunnel through volar wrist Test function Opposition of thumb to each finger Observe thenar muscles for contractions,03/04/2014,03
6、/04/2014,Nerve Injury,Radial Nerve Motor Innervates extrinsic wrist and finger extensors Does not innervate any intrinsic muscles Sensation Dorsally for 3.5 fingers Cutaneous innervation image Test function Wrist and hand extension against resistance,03/04/2014,03/04/2014,Examination and diagnosis,E
7、xamination of the wound Size and location Depth of the wound Blood circulation Blood vessel injury Nerve injury Tendon injury Bone and joint injury X-ray,03/04/2014,First aid,Stop bleeding Reduce contamination Temporary fixation Transportation to a hospital,03/04/2014,Debridement,In 6-8hours Washing
8、 Removal of dead tissue,03/04/2014,Repair,Bone and joint Vessel Tendon and ligament Nerve Skin,03/04/2014,手部骨与关节损伤处理,General Principles of Hand Fracture Management Avoid over-immobilization Correct angular malalignment and rotation Splint in position of moderate flexion Avoid splinting fingers in ex
9、tension (esp MCP) Axes of all flexed fingers should point at Scaphoid Evaluate peri-articular fractures for avulsed tendon Fragments are often attached to a tendon or ligament,03/04/2014,手部骨与关节损伤处理,Consider Open Reduction and Internal Fixation (ORIF) Advantages Avoid excessive manipulation Avoids pr
10、olonged splinting Indications Unstable displaced intra-articular fractures if 25-30% of joint surface involved,03/04/2014,03/04/2014,Prognosis,Replantation,What is replantation?,Replantation refers to the surgical reattachment of a finger, hand, or arm that has been completely cut from a persons bod
11、y.,03/04/2014,The goal of replantation surgery,to give the patient back as much use of the injured area as possible. In some cases, replantation is not possible because the part is too damaged. If the lost part cannot be reattached, a patient may have to use a prosthesis (a device that substitutes f
12、or a missing part of the body). In some cases, a prosthesis may give a person without hands or arms the ability to function.,03/04/2014,First Aid,Stop bleeding Reduce contamination Protect Limb/finger Transportation to a hospital,03/04/2014,Indications of replantation,Replantation is usually recomme
13、nded when the replanted part will work at least as well as a prosthesis. Generally, a missing hand would not be replanted knowing that it would not work, be painful, or get in the way of everyday life. Before surgery the doctor, if possible, will explain the procedure and how much use is likely to r
14、eturn following replantation. The patient or family member must decide whether that amount of use justifies the long and difficult operation, time in the hospital, and months or years of rehabilitation.,03/04/2014,Treatment after replatation,The patient has the most important role in the recovery pr
15、ocess. Smoking causes poor circulation and may cause loss of blood flow to the replanted part. Allowing the replanted part to hang below heart level may also cause poor circulation. Younger patients have a better chance of their nerves growing back, they may regain more feeling, and may regain more
16、movement in the replanted part.,03/04/2014,Prognosis,Generally, the further down the arm the injury occurs, the better the return of use to the patient. Patients who have not injured the joint will get more movement back than those who have. A cleanly cut part usually works better after replantation
17、 than one that has been crushed or pulled off. Recovery of use depends on regrowth of two types of nerves: sensory nerves that let you feel, and motor nerves that tell your muscles to move. Nerves grow about an inch per month. The replanted part never regains 100% of its original use. Most doctors c
18、onsider 60% to 80% an excellent result. Cold weather can be uncomfortable and a frequent complaint even for those with excellent recovery.,03/04/2014,Rehabilitation,Complete healing of the injury and surgical wounds is only the beginning of a long process of rehabilitation. Therapy and temporary bra
19、cing are important to the recovery process. From the beginning, braces are used to protect the newly repaired tendons and allow the patient to move the replanted part. Therapy with limited motion helps keep joints from getting stiff, muscles moving, and scar tissue to a minimum. Even after you have
20、recovered fully, you may find that you cannot do everything you wish to do. Tailor-made devices may help many patients do special activities or hobbies. Many replant patients are able to return to the jobs they held before the injury. When this is not possible, patients can seek assistance in select
21、ing a new type of work.,03/04/2014,03/04/2014,Secondary surgery may be needed,Some of the most common procedures are: Tenolysis - frees tendons from scar tissue. Capsulotomy - releases stiff, locked joints. Tendon or muscle transfer - moves tendons or muscles to another spot so that they can work in
22、 an area that needs the tendon or muscle more. Nerve grafting - replaces a scarred nerve or a gap in the nerves to improve how the nerve works. Late amputation - removing the part later because it does not work or has become painful.,Take home messages,Hand injury includes the injury of Skin Vessels
23、 Tendon Nerve Bone and joint All of these tissues need to be repaired or reconstructed.,Reference Books,1Principles of Orthopedic Practice。Dee Hust, Gruber Kottmeier。世界图书出版公司，1997 2CAMPBELLS OPERATIVE ORTHOPAEDICS(第九版) 3实用骨科学（第二版）。胥少汀等主编。人民军医出版社；2003 4Hand Surgery Update。Paul R Manske。American Academy of Orthopedic Surgeons, 1996 5骨折及关节损伤的处理（VCD）。大连医科大学。人民卫生出版社；2004 6断肢（指）再植（VCD）。白求恩医科大学。人民卫生出版社；2004,03/04/2014,谢谢,
