THE EARLY TREATMENT OF HAND INJURIES

Abstract

For first aid the wound is covered by a sterile dressing and the patient. taken to a well-equipped surgery where the definitive treatment is done under the best aseptic surgical conditions. A careful examination and diagnosis of the injured structures is made. A plan of reconstruction is then decided upon. Consideration is given to the patient, his work, and his outlook. At this first treatment, digits may even be made to oppose each other for practical prehension and a plan of cover may be provided. One should consider what is left of the hand and the best way to preserve it and utilize it for prehension and sensation. Early treatment is merely the acute phase of plastic, orthopaedic, and peripheral-nerve surgery, all of which are needed for hand surgery. The surrounding parts are shaved, washed with soap and water, and the wound is thoroughly irrigated with normal salt solution. Aseptic precautions are taken not to contaminate the wound with virulent germs from mouth and nose droplets or other contacts. The field is rendered bloodless by a pneumatic tourniquet, and the wound is debrided with as little trauma as possible. All usable parts are saved, particularly the nerves and tendons. Fractured bones are set, digits are placed in a position of function, and the skin cover is applied. Maximal length of the thumb is saved, and good workable cover is provided to the digital stumps. If a digit is discarded, its skin with vessels and nerves may be utilized for cover. At first the damage is solely from the injury, but later there may be many complications, such as stiffened joints in the position of non-function and the others of the six main types of crippling already described in detail. These may be superimposed on the injury, but are directly due to the treatment. Stiffening may be prevented by affording cover early, with the use of even a pedicle graft if necessary, by preventing infection, and by avoiding swelling and maintaining activity. The available measures to prevent infection are early operation, early covering of all vulnerable parts with skin, the use of antibiotics, and refraining from attempting repair of deep structures where the wound is too old or too much traumatized. Swelling can be avoided by elevation, fluff pressure dressings, and activity of the hand, exercising as much of it as possible and as early as possible, until the return to work. Flexion contractures are avoided by preventing infection, establishing cover early, avoiding excess of granulations, and maintaining the position of function. The latter is maintained by attentions to the key joints, keeping the wrist. in dorsiflexion, the proximal finger joints in flexion, the metacarpal arch curved, and the thumb in moderate opposition. Elastic splints may be used to change the deformed hand to one in the positions of function. Malalignment of bones is prevented by setting fractures and reducing dislocations early. Motion is preserved by repairing muscles and tendons early, whenever conditions permit, but never late in wounds or in traumatized tissue. Paralysis and loss of sensation are guarded against by recognizing early that nerves are injured and repairing them as soon as the conditions are right. The repair is usually done temporarily by merely securing the nerve ends together with one stitch of stainless-steel wire; secondary careful repair is done later. It is important that nerve repair be given priority over that of bones and joints, or fibrous degeneration of muscles and nerves will become irreversible. Ischaemic contractures are avoided by not constricting the forearm and hand with dressings or casts, especially in the anticubital space and over the hand itself. A developing contracture may be aborted by prompt. decompression and freeing the vessels. Vasomotor disturbances are prevented by early recognition of the condition and by insisting on activity and the performance of work by the involved hands. On reviewing these six main types of crippling and their mechanism of production, it is seen that much of the disability from injured hands can be prevented.