Hand Trauma Detailed Information

Introduction of Disease,Classification of Disease,Clinical Presentation,First Aid Measures,Open Injury,Closed Injury,Treatment of Disease,Early Injury Evaluation,Selection of Anesthesia,Emergency Cleansing,Intraoperative Injury Evaluation,Repair and Reconstruction,Post-Operative Treatment, Introduction of Disease The hand is the most commonly used organ in daily life and at work, and it needs to be constantly in contact with tools and objects in case of trauma (e.g., fall or impact) due to its reflexive support. Since the hands are not protected in most cases and are in constant contact with various tools and objects, their reflexes to support and back up in case of traumatic injuries (e.g., falls or impacts) make them one of the most vulnerable parts of the body. Because of the importance of the hands, how to correctly deal with hand trauma, so that it can be faster, more complete functional and cosmetic recovery, has become the majority of patients and hand surgeons **** the same concern. In fact, long-term clinical practice has proved that only doctors and patients **** the same efforts, in order to make the recovery of hand trauma to achieve satisfactory results. In the treatment process of hand trauma, in addition to the doctor's accurate judgment and appropriate treatment, the patient's cooperation and reasonable functional exercise is also crucial. It is hoped that this article can make hand trauma patients and their families have a relatively preliminary understanding of this type of injury and its treatment principles, and be able to understand to a certain extent the therapeutic purposes and means of hand surgery specialists, in order to actively cooperate with the doctor's treatment and rehabilitation. Disease classification According to different criteria, hand trauma can be divided into many different categories, but for the general public, hand trauma can be divided into two categories: open injury and closed injury. Open injuries: open injuries refer to hand trauma with skin breakage. Second, closed injury: for closed injury, most patients are easy to ignore its seriousness. Clinical manifestations I. Open injuries: such injuries are often combined with bleeding, pain, swelling, deformity and/or dysfunction. Closed injuries: closed injuries due to the skin intact, while the subcutaneous tissue after the injury serious swelling, easy to lead to the skin will be swollen soft tissues tightly strangulation, so that the local blood circulation is impaired, some patients may even lead to the distal limb or soft tissue necrosis. First Aid Measures Open Injury I. First Aid Principle It must be dealt with in time. Generally speaking, open injury should strive to close the wound within 6-8 hours after the injury, so as to minimize the occurrence of postoperative infection to a great extent. First aid 1. In the event of open hand trauma, the nearest hospital should be sent to the hospital in time for treatment, and tetanus antitoxin should be routinely injected. 2. In the process of sending to the hospital, if there is more serious bleeding, it is feasible to apply local pressure, or use a belt or leather band in the upper arm to stop bleeding, but if this method is used to stop bleeding, it must be noted that when every ring is tied for about 1 hour, it is necessary to release the belt or leather band for 10-15 minutes, otherwise it will lead to the necrosis of the whole limb. 3. If the injury results in a fracture of the limb, it is best to carry out a simple fixation before handling, can be nearby materials, with a wooden board, iron bars or harder books, magazines can be, in this way, you can avoid in the process of handling the fracture broken end of the secondary damage to the surrounding nerves, blood vessels, tendons and other soft tissues. 4. If there is a severed limb or finger injury, it is best to wrap the severed limb or finger in a plastic bag, place it in a low-temperature insulation bucket for preservation, and send it to the hospital together with the patient, and avoid freezing and preservation of the residual limb or placing the residual limb in icy water directly (as shown in the figure). Closed injury First aid principle: In the case of closed injury, you should also seek medical treatment in time, so that the doctor can give a comprehensive and accurate judgment of the injury, so as not to delay the early treatment. If the patient feels obvious swelling of the limb, appearing pale or blue hand, numbness of the fingers, radial artery pulsation disappears, etc., it is even more important to rush to the doctor for timely treatment. Disease Treatment Early Injury Assessment Because the structure of the hand is very delicate and complex, it is very important to determine how to accurately determine the injury after the injury. In hand trauma, the skin is often the first tissue involved, followed by muscles, tendons, nerves, blood vessels, and bone and joints. 1. Skin injury judgment: Skin breakage is very intuitive, however, different types of skin breakage, its prognosis is also different, the skin of the sharp cuts relatively easy to dispose of, and carding machine injuries or large areas of skin peeling or defects is very tricky. Since carding machine injuries cut the skin into strands, they are almost impossible to repair with good sutures. Large skin exfoliation injuries, on the other hand, often make it difficult to determine whether the exfoliated skin is still viable and whether it will become necrotic upon replantation. Even sharp cuts to the skin are not to be taken lightly. If a cut is made by a meat cleaver, the knife is contaminated with heterologous proteins such as meat slurry, making the wound very susceptible to infection and non-healing, and the same can be said for human or animal bite wounds. 2. Nerve injury: If the injury site is far away from the sensory loss, loss of sensation and (or) movement disorders, we should be highly suspicious of whether the injury to the nerve, at this time, to the general hospital to clean the wound suture is not enough, we must go to the hand surgery specialists, and strive for early repair of the nerve injury, in order to achieve the best possible results. 3. Judgment of vascular injury: In open injury, bleeding is inevitable, however, if there is wound jet bleeding, it may injure the artery, at this time, it is necessary to promptly carry out pressure to stop bleeding, or in its proximal end of the tourniquet to stop the bleeding, otherwise, the patient may soon be due to loss of blood and shock, or even life-threatening. In addition, if the wound distal pale, pulseless, skin temperature significantly reduced, more suggest that the part of the blood flow is very poor, not anastomosis of blood vessels, re-establish blood circulation, the limb can not be preserved, at this time, the patient should be sent directly to the hand surgery specialist hospital treatment, so as to avoid repeated transfers and delayed treatment. 4. Muscle and tendon injuries: If one or more fingers have impaired mobility without loss of sensation, it may be due to tendon or muscle injuries, which should be repaired by a hand surgeon. 5. Bone and joint injuries: If there are deformities in the bone and joint parts, abnormal activities, or localized swelling and pressure pain, it suggests that there is a possibility of bone and joint injuries, and at this time, we should take a clear picture of the severity of the injuries. When taking hand radiographs, we should pay attention to the fact that we should not only take orthopantomograms and oblique radiographs of the whole hand, but also take orthopantomograms, lateral radiographs and oblique radiographs of a specific finger or joint. In this way, the diagnosis will not be missed. Anesthesia selection Most general hospitals do not pay much attention to hand trauma, and often perform surgery with simple local anesthesia in the emergency operating room. However, due to the poor analgesic effect of local anesthesia and the small scope of anesthesia, it is not conducive to thorough debridement and comprehensive exploration of the injury, which may easily lead to incomplete debridement or missed diagnosis and treatment. Generally speaking, it is recommended to choose brachial plexus nerve block anesthesia for hand trauma, so that the anesthesia can basically cover the whole upper limb, and it is also convenient to use a pneumatic tourniquet, which not only reduces the bleeding during the operation, but also makes the surgical field cleaner, which is conducive to improving the efficiency of the operation. Of course, if only the end of the finger is injured and no other flap transposition surgery is considered, finger root anesthesia combined with the use of finger root tourniquet can also be performed. At present, the more popular root anesthesia is to perform flexor tendon sheath injection anesthesia, the advantage of this anesthesia is that only one injection can achieve the effect of anesthesia, the patient's pain is small, and the effect of anesthesia is certain. General anesthesia may be considered if there are multiple limb injuries, or if a flap or tissue flap transposition procedure is planned for another site, or if the patient is a pediatric patient who cannot cooperate with anesthesia. Emergency debridement Emergency debridement of open wounds is crucial, and the quality of debridement directly determines whether or not the patient's postoperative wounds can heal in one stage and whether or not infection will occur. During debridement, necrotic and inactivated tissues as well as severely contaminated tissues should be removed as thoroughly as possible, and then the wound should be repeatedly flushed with saline, hydrogen peroxide and iodine povidone, and after that, if necessary, a second debridement should be performed until the wound is clean and fresh. Previous hand surgery textbooks have placed great emphasis on thorough debridement, i.e., removing all contaminated tissues and reconstructing important tissues after thorough debridement. However, for many important tissues (e.g., nerves, trunk arteries, etc.), once removed, the reconstruction results may not be satisfactory, coupled with the progress of modern antibiotic technology, the surgeon can, in some cases, carry out limited debridement, retaining some of the important tissues that have been lightly contaminated, or only stripping the contaminated epithelial tissues, and then, through the local contaminated tissues of the etiological culture and drug sensitivity experiments, supplemented with the use of topical or systemic antimicrobial agents, in order to achieve the best result. Through the pathogenic culture of local contaminated tissues and drug sensitivity test, supplemented with local or systemic antimicrobials, to try to preserve the function of the affected limb. For cases with severe contamination and prolonged wound opening, the possibility of P. aeruginosa infection should be considered, so a smear of the wound exudate should be performed before surgery to check for the presence of gram-positive Corynebacterium vulnificum or P. aeruginosa, and if P. aeruginosa infection is suspected, the surgery should be performed in a separate isolated surgical room, and the surgical wound should not be closed in a single stage (or after debridement, repeated smear should be taken to confirm that there is no more C. aeruginosa or P. aeruginosa). The surgical wound should not be closed in one stage (or the wound should be closed only after repeated smears after debridement to confirm that there is no more P. aeruginosa or bacilli), and postoperative hyperbaric oxygen therapy may be adjunctive if available. Intraoperative wound assessment During surgery, after debridement, the surgeon should further confirm the results of the preoperative wound assessment. If new injuries are found, they should be recorded in detail and repaired in one stage if possible. Repair and reconstruction If the wound is not particularly contaminated, one-stage tissue repair and reconstruction is advocated for all traumatic injuries to the hand. Whether it is the skin, tendons, bones or nerves, if there is a defect, tissue grafting should be performed, except in some special cases, because if it is forced to fit together, it is likely to result in contracture or shortening of the tissues which will seriously affect the function and appearance. Of course, in the case of serious contamination of the wound, there is a certain risk to carry out the first phase of tissue repair, in this case can also be temporarily debridement, to be followed by the second phase of tissue repair and reconstruction. Postoperative treatment Hand wounds are usually removed in 2 days, if the wound is placed in the drainage tube, depending on the amount of drainage flow to determine the time of removal, usually in 24 hours when the drainage flow is less than 15 ml can be removed. If the hand wound is not infected, there is no need to change the dressing frequently, and it is enough to change the dressing once in 5-7 days. If the wound exudes more, the medicine can be changed once in 1-2 days. If the patient's blood sugar is normal and the wound is not infected, the stitches can be removed 12-14 days after surgery. For diabetic patients, suture removal can be delayed. Patients after replantation of amputated fingers (amputated limbs), combined vascular injury or after free tissue transplantation should minimize all kinds of factors inducing vasoconstriction in the postoperative period, so as to avoid surgical failure due to postoperative vascular crisis. First of all, we should minimize the pain *** , we can use painkillers, pain pumps, etc. Secondly, we should try to avoid the cold and cigarettes *** . Of course, it would be better to use appropriate antispasmodic and vasodilator medications if available, or use a baking lamp to irradiate the affected limb. For patients with combined blood vessel, tendon and nerve injuries, generally after the operation will be assisted with plaster fixation, such casts generally need to be fixed for 3-4 weeks, during the period of plaster fixation, do not remove the plaster without authorization, otherwise it will easily lead to the suture of the blood vessels, tendons or nerves again rupture. After the removal of the plaster, functional exercises should be carried out under the guidance of the doctor, and various supports can also be used for the immobilization of patients with special requirements or patients who are allergic to plaster. For patients who still have partial dysfunction after functional exercise, secondary surgery can be considered 4-6 months after the first surgery for tissue release, repair or functional reconstruction surgery.