1. General Principles of Management and open fractures
– one great pitfall is to focus on the obvious fracture and neglect the soft tissue injuries (or other bony injuries) – BE CAREFUL!!!
– the nature of foreign bodies influences the best imaging technique – ultrasound, x-ray, CT, MRI.
– anesthesia is often best done locally – combined median and radial nerve blocks at the wrist, along with ulnar nerve and dorsal sensory branch block. DO NOT USE EPINEPHRINE
Gustillo classification not very applicable in the hand.
– Classification by Swanson et al. developed for the hand:
Type I – clean wound, no significant contamination, no significant delay in treatment, no systemic illness
Type II – contaminated wound (dirt, debris), bites, river/lake injuries, barnyard injuries, systemic illness, delay > 24 hours to treatment
– antibiotics are probably not necessary for Type I wounds – more important to have copious irrigation after thorough debridement; Type II wounds should have ancef, or the addition of an aminoglycoside and/or penicillin
– Type I wounds can be closed primarily
Massive Hand Trauma
– all hand wounds do not require primary closure
– unfortunately, there is a dichotomy between the needs of bony injury and the needs of soft tissue injury in these cases. The bones often require STABILITY, while the soft tissues need MOBILITY to prevent scar formation and contracture. Finding the ideal compromise is often very difficult.
– maintain the thumb-index webspace by stabilizing the thumb metacarpal in full palmar abduction – this prevents a significant, functionally compromising webspace contracture
– Delayed Primary Repair: the principle is to perform definitive operative repair several days after injury after thorough debridement (definitive operative repair would include ORIF, skin grafting, bone grafting, etc…)
– Preserving skeletal length is important for later reconstruction – can do this with K-wires