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Original Article
DOI: 10.4103/2229-5151.124101 Quick Response Code:
A study of hand injury and emergency management in a developing country Soumya Ghosh, Ritesh Kumar Sinha, Soma Datta1, Arunima Chaudhuri2, Chinmoy Dey3, Abhinay Singh
ABSTRACT Background: Injury to the underlying structures of the hand carries the potential for serious handicap. To reduce this risk, even the smallest hand injuries require proper medical care. Aims: To assess wound healing, mobility, and the ability to perform normal essential function post‑operatively in open hand injuries associated with fracture. Materials and Methods: Thirty patients with 45 metacarpal and phalangeal fractures of the hand were divided into three groups: Group 1 (n = 13) cases with single fractures of hand, excluding thumb; Group 2 (n = 9) cases with multiple fracture of hand, excluding thumb; Group 3 (n = 8) cases with fractures involving thumb and first metacarpal. Tendon injuries were repaired. For fractures, Kirschner wire fixation was done. In two cases with multiple fractures, Joshi’s external support system (JESS) fixator was applied. Patients were followed up for 12 weeks.
Departments of Orthopaedics, 1 Pathology, 2Physiology, Burdwan Medical College and Hospital, Burdwan, 3 Department of Orthopaedics, Nil Ratan Sarkar Medical College and Hospital, Kolkata, West Bengal, India Address for correspondence: Dr. Arunima Chaudhuri, Krishnasayar South, Borehat, Burdwan ‑ 713 102, West Bengal, India. E‑mail: [email protected]
Results: One patient with proximal phalangeal fracture developed extension lag. No stiffness was observed in any of the cases treated by intramedullary Kirschner wire fixation. No non‑union or delayed union was observed following cross‑wire fixation with two Kirschner wires. Two case of open fracture developed superficial infection. Two patients with multiple fractures developed angulation at fracture site after the Kirschner wires were removed 4 weeks postoperatively, and two cases of multiple fractures developed hypertrophic non‑union. Conclusions: Delicate handling of tissues, preservation of gliding planes for tendons, prevention of infection, accurate reduction and fixation, and early and appropriate physiotherapy affect prognosis in case of hand injuries. Key Words: Hand injury, management, prognosis
INTRODUCTION Hands are instruments of performance and protection. Any injury to the underlying structures of the hand carries the potential for serious handicap. To reduce this risk, even the smallest hand injuries require proper medical care. Hand injuries are relatively common and account for 5-10% of emergency department visits.[1,2] The most common mechanisms of open hand injury are road traffic accidents, blunt trauma (e.g. crush injury, contusions), and assault.[1,2] Mutilating hand injuries may be classified by the
scheme of orientation, wound type, and zone of injury according to Tic Tac Toe classification [Table 1] by American Society for Surgery of the Hand (ASSH) as follows:[3] Zones of injury are shown in Table 2. Open fractures of hand can be classified according to Gustilo Andersons Classification System. [4] Type I: 1 cm laceration with no extensive soft tissue damage, skin flap, or avulsion. Extensive soft tissue damage or flaps, but adequate
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
229
Ghosh, et al.: Hand injury
Table 1: Wound type and Zone of injury according to Tic Tac Toe classification Orientation
I II III IV V VI VII
Dorsal Palmar Ulnar Radial Transverse Degloving Combined
Wound subtype
A B C 1 2
Soft tissue loss Bony loss Combined tissue loss Vascularized Devascularized
Table 2: Zone of injury Zone
Radial
Central
Ulnar
Distal
I: Thumb, P1, P2 IV: Thumb, Metacarpal VII: Scaphoid, Trapezium, Trapezoid
II: Index, Middle P1, P2, P3 V: Index, Middle, Metacarpal VIII: Capitate, Lunate
III: Ring, Small P1, P2, P3 VI: Ring, Small Metacarpal IX: Hamate, Triquetrum, Pisiform
Central Proximal
coverage of bone or high energy trauma regardless of size of the wound (like comminuted or segmental fractures even those of
Original Article
DOI: 10.4103/2229-5151.124101 Quick Response Code:
A study of hand injury and emergency management in a developing country Soumya Ghosh, Ritesh Kumar Sinha, Soma Datta1, Arunima Chaudhuri2, Chinmoy Dey3, Abhinay Singh
ABSTRACT Background: Injury to the underlying structures of the hand carries the potential for serious handicap. To reduce this risk, even the smallest hand injuries require proper medical care. Aims: To assess wound healing, mobility, and the ability to perform normal essential function post‑operatively in open hand injuries associated with fracture. Materials and Methods: Thirty patients with 45 metacarpal and phalangeal fractures of the hand were divided into three groups: Group 1 (n = 13) cases with single fractures of hand, excluding thumb; Group 2 (n = 9) cases with multiple fracture of hand, excluding thumb; Group 3 (n = 8) cases with fractures involving thumb and first metacarpal. Tendon injuries were repaired. For fractures, Kirschner wire fixation was done. In two cases with multiple fractures, Joshi’s external support system (JESS) fixator was applied. Patients were followed up for 12 weeks.
Departments of Orthopaedics, 1 Pathology, 2Physiology, Burdwan Medical College and Hospital, Burdwan, 3 Department of Orthopaedics, Nil Ratan Sarkar Medical College and Hospital, Kolkata, West Bengal, India Address for correspondence: Dr. Arunima Chaudhuri, Krishnasayar South, Borehat, Burdwan ‑ 713 102, West Bengal, India. E‑mail: [email protected]
Results: One patient with proximal phalangeal fracture developed extension lag. No stiffness was observed in any of the cases treated by intramedullary Kirschner wire fixation. No non‑union or delayed union was observed following cross‑wire fixation with two Kirschner wires. Two case of open fracture developed superficial infection. Two patients with multiple fractures developed angulation at fracture site after the Kirschner wires were removed 4 weeks postoperatively, and two cases of multiple fractures developed hypertrophic non‑union. Conclusions: Delicate handling of tissues, preservation of gliding planes for tendons, prevention of infection, accurate reduction and fixation, and early and appropriate physiotherapy affect prognosis in case of hand injuries. Key Words: Hand injury, management, prognosis
INTRODUCTION Hands are instruments of performance and protection. Any injury to the underlying structures of the hand carries the potential for serious handicap. To reduce this risk, even the smallest hand injuries require proper medical care. Hand injuries are relatively common and account for 5-10% of emergency department visits.[1,2] The most common mechanisms of open hand injury are road traffic accidents, blunt trauma (e.g. crush injury, contusions), and assault.[1,2] Mutilating hand injuries may be classified by the
scheme of orientation, wound type, and zone of injury according to Tic Tac Toe classification [Table 1] by American Society for Surgery of the Hand (ASSH) as follows:[3] Zones of injury are shown in Table 2. Open fractures of hand can be classified according to Gustilo Andersons Classification System. [4] Type I: 1 cm laceration with no extensive soft tissue damage, skin flap, or avulsion. Extensive soft tissue damage or flaps, but adequate
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
229
Ghosh, et al.: Hand injury
Table 1: Wound type and Zone of injury according to Tic Tac Toe classification Orientation
I II III IV V VI VII
Dorsal Palmar Ulnar Radial Transverse Degloving Combined
Wound subtype
A B C 1 2
Soft tissue loss Bony loss Combined tissue loss Vascularized Devascularized
Table 2: Zone of injury Zone
Radial
Central
Ulnar
Distal
I: Thumb, P1, P2 IV: Thumb, Metacarpal VII: Scaphoid, Trapezium, Trapezoid
II: Index, Middle P1, P2, P3 V: Index, Middle, Metacarpal VIII: Capitate, Lunate
III: Ring, Small P1, P2, P3 VI: Ring, Small Metacarpal IX: Hamate, Triquetrum, Pisiform
Central Proximal
coverage of bone or high energy trauma regardless of size of the wound (like comminuted or segmental fractures even those of
