of the Hand and Wrist

Fig. 20.1

Useful active or passive exercises to teach a patient and his family after hand or wrist injury for ROM and edema reduction. (a) Fully extend MP and IP joints. (b) Flex MP joints with IP joints extended. (c) Extend MP joints with IP joints flexed. (d) Make a fist. (e) Abduct and adduct fingers. (f) Touch thumb to tips of fingers

Rings, bracelets, and armbands are common jewelry and need to be removed after any upper extremity injury. It is unlikely one will find a ring cutter, and sometimes the only instrument is a bolt cutter. In many cultures, religious strings or braids are worn around an extremity. Patients usually object to their removal. Local staff can help explain the need for removal and the patients usually comply, especially if the talisman is retied around the cast.

One of the major drawbacks to nonoperative treatment is the need for frequent early checks to determine the continued proper position of the fracture or adjustment of the immobilization as swelling subsides. For patients who live far from the hospital and for whom lengthy inpatient treatment is not possible, fracture reduction with pinning may be a more conservative approach than simply reduction and casting.

The good outcomes hand and upper extremity surgeons enjoy in high-resource countries depend in large part on hand therapists. With few therapists in developing countries, the surgeon must take on this added role. The surgeon needs to think creatively about how to solve the immediate problems for the patient’s advantage.

Equipment and Instruments

Pneumatic Tourniquet

Check if one is present and is the right size for upper extremity work and functions. Esmarch bandages are often used both to exsanguinate and to wrap proximally as tourniquets. They should be used with extreme caution as they can cause severe nerve injury as there is no control over the pressure applied.

Finger Traps

If not available, a simple long gauze made into a “rope” and looped around two fingers with a counterweight on the upper arm substitutes well (Fig. 20.2).

../images/270913_2_En_20_Chapter/270913_2_En_20_Fig2_HTML.png — Fig. 20.2

Makeshift elevator made of Kerlix or long bandage gauze to assist in fracture reduction and casting

C-Arm

The presence of one in the operating theater does not mean it functions. Assess the quality of the image before planning cases that are dependent on fluoroscopy. Make sure lead protection is available for everyone in the room.

Hand Instruments

Make sure suitable small instruments are available and that they function, e.g., the tips of the forceps meet and the tenotomy scissors actually cut. Hospital staff are often reluctant to discard unusable instruments, knowing they won’t be replaced, and return them in the instrument tray for “completeness.”

K-Wires

Hospitals often buy K-wires in long lengths, allowing surgeons to cut off what they need. When cut with a dull pin cutter and the incomplete cut is repeatedly worked to complete the cut, the pin is generally out of true and has a burr at the end. Check the size, trueness, and tip points of K-wires before starting a case.

Power Drills

These are expensive and rarely present or are broken or have no wire driver attachment. Sometimes the chuck only accepts large pins. It is thought by some staff that the bones in the hand are small, making power unnecessary. A manual drill is difficult for someone used to working only with power, especially when trying to pin and, at the same time, hold small bone fragments in position. A Jacobs Chuck on a T handle may be more useful.

Lead Hand

Most hospitals in low-resource countries have workshops where a sheet of lead can be cut to make a lead hand or one can be made in the local bazaar.

Upper Extremity Injury with Tendon or Nerve Involvement

If appropriate sutures, instruments, or expertise are not present to repair injured tendons or nerves, it is best to clean the wound, loosely close the skin, and apply a splint in the functional position to avoid further injury and instructions for elevation and passive ROM of the fingers. These repairs can be completed weeks later with good results if there is no infection and the soft tissues are stable. Poor, inadequate, or overly aggressive initial treatments can make a functional outcome impossible.

If one is comfortable repairing tendons and nerves and has the equipment, do not be heroic. Weigh the risks of equipment challenges and availability of hand therapy against hope for good outcome and be realistic. With multiple flexor tendon and nerve injuries, such as a deep slash or cut across the volar wrist, concentrate on repairing the flexor pollicis longus, one wrist flexor, the profundus tendons, and the median nerve. A modified Kessler core suture is recommended for the tendons (video of flexor tendon repair: https://www.searchencrypt.com/videos?eq=E8pos4cXhw4EWpdqVsYE4KaiYpUSRSJWdSpWY7T%2B6x4sOPlD2o3pLr2p2aubL0va). The nerve can be sutured with an epineural repair. Tendon repair distal to the distal palmar crease is not recommended for the inexperienced. Splint with a dorsal plaster of Paris slab that extends beyond the tips of the fingers (include the thumb if involved) with the wrist in 15–20° palmar flexion, the MPs at 45–50° flexion, and the IPs extended. Unless trained physiotherapists are available, it is usually best to splint patients for 4–6 weeks post-repair. Only in carefully selected patients is early motion a good option.

Lacerations and injuries of the extensor tendons across the phalanges where the tendons have thinned and broadened into the intricate extensor hood are difficult to suture. In crush or avulsion injuries, whole areas of the hood may be missing which may require flap coverage. The extensor tendons over the metacarpals and proximally in the forearm are more discrete and can be repaired with either a figure of eight suture or a Kessler-type suture. With loss of extensor tendon continuity proximal to the MP joints that cannot be bridged, it may be possible to reattach the cut distal end of the tendon to an adjacent intact tendon or mobilize one of the proprius tendons as a graft. Postoperative splinting is with the wrist in 30–40° dorsiflexion and MPs in slight flexion and PIP in extension for 4 weeks. Take care to leave intact the dorsal retinaculum to prevent tendon bow stringing.

Fractures of the Distal Radius and Ulna

Colles-type fractures in which the distal fragment is dorsally displaced with apex volar angulation can usually be treated with closed reduction. The Charnley dorsal-radial splint controls both the dorsal and radial deformities (Fig. 20.3). It can be used as part of a sugar tongs or a below-elbow splint throughout the 6–8 weeks of treatment, by periodically adjusting the bandages as swelling decreases, or it can be converted into a circumferential POP (plaster of Paris). It is especially useful in elderly patients whose loose skin makes edema problematic.

../images/270913_2_En_20_Chapter/270913_2_En_20_Fig3a_HTML.jpg — Fig. 20.3

Dorsal-radial splint. (a, b) X-ray of distal radius fragility fracture. (c) Outline of proposed splint on a 6″ wide plaster slab. This is faced with cotton and can be used for either left or right injuries. (d) Splint applied on the dorsal and radial sides of the forearm and wrist and (e) wrapped with a bandage, which can be resecured and tightened as swelling subsides

../images/270913_2_En_20_Chapter/270913_2_En_20_Fig3b_HTML.png — Fig. 20.3

Dorsal-radial splint. (a, b) X-ray of distal radius fragility fracture. (c) Outline of proposed splint on a 6″ wide plaster slab. This is faced with cotton and can be used for either left or right injuries. (d) Splint applied on the dorsal and radial sides of the forearm and wrist and (e) wrapped with a bandage, which can be resecured and tightened as swelling subsides

Unstable fractures or those that lose reduction may benefit from percutaneous pinning. Intraoperative C-arm control helps with pin placement, but two-part extra-articular fractures can be pinned without C-arm using the Kapandji technique of intra-focal pinning. A small dorsal-radial incision allows fracture identification. One or two 0.62 K-wires are introduced into the fracture so they both reduce the fracture and dorsally buttress the distal fragment to hold the reduction. Once the K-wire is placed into the fracture, it can be drilled or tapped into the metaphyseal bone and cortex of the proximal fragment. If percutaneous pins are supported with a circumferential POP, ensure that the pin-skin interface is well padded and the pins do not press directly on the skin. Extending the plaster over the thumb MP joint prevents irritation due to thumb motion near a radial pin.

A wrist-spanning external fixator can be used to maintain alignment and length, with or without percutaneous pinning of the fracture. Pins and plaster can produce similar results as an ex-fix but without the ease of future adjustment. For reducing and fixing comminuted intra-articular distal radius fractures, a C-arm is necessary for percutaneous technique and is helpful for open reduction, but not mandatory.

Smith-type fractures—apex dorsal angulation—can usually be held in a POP with volar distal molding, taking care that no pressure is placed along the median nerve. Adding a short thumb spica to the cast will give a broader molding platform to control the distal fragment. A 0.62 K-wire will hold the fracture if a POP doesn’t.

Certain intra-articular radius fractures are fracture/dislocations (Fig. 20.4). Postreduction and follow-up x-rays need to confirm capitellar-lunate alignment with the long axis of the radius. If the fracture fragments or the wrist alignment can’t be reduced and held with a percutaneous pin, an open reduction and pinning is needed.