Birth Defects (In Detail)
All Hand Injuries
Replants and Revascularizations
All Hand and Foot Tumours (In Detail)
Hand Contractures
Compression Neuropathy
Compound Fractures (In Detail)

An injured hand is often the dominant hand of the only bread-earner of a family and the incapacitation it causes not only effects the livelihood of the patient but the well being of the entire family. It is possible to examine, document and analyze hand functions, or the lack of it, but the art is in learning how each patient uses these various attributes in his daily life, his occupation, his hobbies and his leisure activities. The challenge is not only to heal the injured hand but to get the person back to his or her profession and give them back their hobbies and simple pleasure pursuits. Now if the demand is that big why are we still trivializing hand injuries and not giving it the respect and recognition it deserves?

In the course of training for General Surgery the special requirements of the Hand seldom receive emphasis even in post-graduate spheres. Hand Injury therefore has traditionally been a Surgical Cinderella, the responsibility of many but the concern of a very few. Again as most patients in the developing world who suffer Hand Injuries belong to the lower socioeconomic strata and are without an insurance back up, this surgery, unlike say Cardiac Surgery, has not attracted publicity, sponsorships and glamour. While a lot of school going children aspire to become Cosmetic Surgeons or Cardiac Surgeons not many of them dream to become Hand Surgeons! It is this image which requires a change and various Hand Societies both National and International, have taken up this image building project in a big way.

The twelve commandments of management of Hand trauma are:

1. The treatment of Hand Injuries should not be regarded as the province of the unskilled. Whether they are Plastic Surgeons or Orthopaedic Surgeons or even General Surgeons, they should have a proper training in Hand Surgery and Microsurgery. Then only they will be able to do justice to all Hand Trauma.
2. Proper instrumentation and operating room facilities should be available.        
3. Atraumatic techniques and complete haemostasis is essential.
4. Viable soft tissues should be preserved and wholesale debridement is a surgical crime.
5. All integument loss should be replaced, skin defects by skin grafts and exposed nerves, bones, joints and tendons by a proper free or pedicled flap.
6. Tendon and nerve repair should be done under magnification, by someone who is trained to do the same These should preferably not be left for a later date as best results are achieved in one stage surgery.
7. Primary positive fixation of fractures is obligatory, but fixation should be confined to the fracture.
8. Oedema, sepsis and pain should be avoided at all cost.
9. Dressing of post-operative patients should be given the same importance as the surgery itself and should not be relegated to the junior most member, or worse still, the unskilled or semi-skilled para-clinical help.
10. Surgical programme for the injured hand should be the briefest possible one so that rehabilitation can commence early. Long periods of hospitalization and multi-staged operations reduce patient’s will to work and his desire to use the hand. Microsurgical techniques have today helped us in achieving this goal
11. The quality of sensation should be recognized as a major factor in the final result of treatment.
12. Team work is essential in the care of the Hand and the patient himself or herself is an important member of the team. Surgery can result in healing without his cooperation but it can not produce function without his active assistance.

A fully developed Hand Surgery service is manned by a multi-disciplinary team comprising of a surgeon, a physician, a physiotherapist, an occupational therapist, a splint technician, a psychologist and social workers. The surgeon being the coordinator of the team is responsible for diagnosis and surgery. These are however the first two steps in the ladder of recovery. Close cooperation and constant inputs from the other members of the team at appropriate time ensures a complete and uneventful recovery.

Crush Injury
Diwali Cracker Burst - Pre-Operation	Diwali Cracker Burst - Post-Operation

No treatment programme is complete without addressing the aspect of prevention. Hand injuries are invariably preventable – whether sustained at home from a faulty electrical appliance, or at work from a poorly designed thresher, or in the factories from carelessness and inexperience. Work exhaustion, fatigue, tobacco and other addictions, irregular supply of electricity are factors which catches one unaware and it is usually one’s hands that pay the price.

REPLANTS AND REVASCULARIZATIONS
(See Microsurgery)

Replantation of limbs and digits are now a reality but the doctors in the periphery need to be educated regarding the storage and transportation of the amputated parts and the patient. All dismembered parts of the body should be put in a clean polythene bag, which in turn should be put in a flask or an icebox containing ice or yet another polythene bag filled with ice. The part should not come in direct contact with ice. It should now be transported by the fastest available conveyance to a Hand Surgery centre, even if the patient is being held back for more pressing emergencies like head or chest injuries. The doctor attending the patient in the emergency should not use his own discretion on whether the amputated parts are replantable or not but should send all the dismembered parts. Even if they are not transplantable in their original location they can serve as valuable sources of auto-graft for other locations. Thus a toe or a vascularised composite graft containing skin, muscle, fascia, bone, tendon and nerve in various combinations can be harvested from a crushed and useless lower limb for transplantation to an equally mutilated upper limb, which thus salvaged will function better than the best available prosthesis.

Forearm Replant - Pre-Operation	Forearm Replant - Post-Operation
Hand Replant - Pre-Operation	Hand Replant - Post-Operation

Revascularization - Pre-Operation	Revascularization - Post-Operation

Not all amputated parts can be replanted. The perils of replantation surgery are:

1. The local tissue destruction

2. The avulsed nature of amputation

3. The proximal level of amputation

4. The large bulk of muscles

5. The mixed nature of nerves

Proximal level of amputation 

·        Vessel repair is easy

·        Permissible ischemia time is less

·        Peripheral nerves are mixed nerves 

Avulsed nature of amputation 

·        Vessels avulsed – extensive intimal damage

·        Nerves avulsed – damage to vasa nervosum

·        Tendons avulsed from myo-tendenous jn.

·        Horner’s Syndrome in higher injuries 

Cooling before revascularization avoids

·        Oedema of amputated part

·        Increased Potassium levels

·        Increased metabolic acidosis ( lactates ) 

Incomplete amputations

·        Splintage – prevent kinking / injury to vessels

·        Artery to be tied - no unsupported artery forceps or tourniquet should be used.       

Irreversibly damaged parts 

These must be transported with the patient as they form invaluable source of skin and fascial flaps and artery, vein, nerve, tendon and bone graft. We have even utilized a great toe and a second toe from an irecoverably damaged below knee amputation part to provide the patient a thumb and a digit to his injured upper limb

Preservation and Transpotration

Part should not

• come in direct contact with ice

• be immersed in water

• be placed in antiseptic fluids-savlon / cidex  

Transportation 

• By the fastest available conveyance

• Amputated part may be sent first while the patient is being resuscitated

• Prior information to the centre always helps

POST BURN CONTRANTURES OF HAND
(See Burns)

Post Burn Contractures of the hand involving the dorsum, flexor aspect of the fingers and thumb and the first web space  are a crippling disability. They in varying combinations render the hand totally incapable of performing basic functions of pinch, hook and grasp. Avoiding them in the early nursing phase of Burns by proper splintage and timely escharectomy and skin grafting followed by physiotherapy remains the best treatment. Once formed, release of these contractures and cover by local, distant or free flaps and subsequent physiotherapy improves the functional capability of these hands considerably. 

172 Post Burn Contracture hands in 164 individuals were surgically treated and 156 of them have returned to their previous vocation. The remaining 8 had to opt for a change in vocation after proper training. Presently all patients are gainfully employed.

ADDUCTION CONTRACTURE THUMB

Adduction contracture of the thumb or 1st. web space contracture effects predominantly the movements of the trapezio-metacarpal joint, rendering the thumb ineffective of opposition, thereby destroying the essential element of grasp and pinch. In a study of 76 hands it was found that it was the dominant hand of the family bread earner, which was most commonly involved, and proper primary management could avoid the development of this contracture. Adequate release of the contractured first web space from hinge to hinge followed by a local skin flap cover and dynamic abduction splintage for the subsequent six weeks gives good results and prevents recurrences. Secondary surgeries like Flexor Pollicis Longus lengthening and opponensplasty are sometimes added to avoid recurrences.

COMPRESSION NEUROPATHY

Despite advances in surgical technique, operative magnification, better suture materials and improved tension less suture techniques, recovery of peripheral nerve function after injury is dependent on many a factors that elude the surgeon. We are unable to alter the process of Wallerian degeneration and the devastating effect it has on the motor end plates, sensory end organs and thus the overall functional capability of the patient. The age of the patient, the level of injury, the mechanism of injury and the flexibility of the patient’s joints and psyche all determine how well a nerve regenerates while the surgeon can only wait, watch and hope. In this not so encouraging scenario, entrapment neuropathy or compression neuropathy remains a silver lining.

Compression Neuropathy refers to a group of syndromes resulting from entrapment or compression of a short segment of a nerve at a specific site. Frequently the nerve is vulnerable where it passes through a fibro-osseous tunnel or an opening in fibrous or muscular tissue. Compression neuropathy refers to nerve damage due to pressure applied to the nerve; entrapment neuropathy applies when the pressure is exerted by some anatomic structure. Therefore, entrapment neuropathies are chronic conditions, but compression neuropathies may be acute.

A careful history including patient’s occupation, metabolic factors, environmental exposure and social milieu is essential to come to a definitive diagnosis. It is always wise to identify the site of neuropathy and then attempt to establish its cause and any contributory associated factors. For instance, a Median neuropathy at the wrist can be from compression, injury, diabetes, hypothyroidism or perhaps repetitive movements across the carpel tunnel. Etiologies may be confusing when neuropathies are related to unsuspected systemic diseases like diabetes, hypothyroidism and gout.

The basic etiology however remains to be a newly developed disparity between the volume of contents of a fibro-osseous / fibro-fascial tunnel and its capacity, which in turn compresses the contained nerve. Causes can be pressure from outside the tunnel, in the wall of the tunnel or inside its lumen and the effect is compression, constriction or mechanical irritation of the contained nerve. Some common nerve entrapment sites and the resulting syndromes are listed in the following table along with hyperlinks for detailed reading and appreciation:

Patients complain of numbness, loss of movement, swelling, prickling, mild-to-severe pain often worse at night, decreased sensation and decreased strength in hand and fingers. Other symptoms may include tendency to drop things and difficulty manipulating small objects. A careful physical examination, Neurological evaluation, Electromyography, Nerve conduction velocity test, and at times MRI, Ultrasound  and X-ray are required to establish the diagnosis. The role of imaging is gaining more and more ground as we encounter unexpected causes of Carpel Tunnel Syndrome preoperatively such as a large adductor pollicis muscle, a persistent Median artery, an excessive amount of fatty tissue within the tunnel, a ganglion cyst and synovial hypertrophy related to rheumatoid arthritis.

Treatment focuses on identifying and removing or correcting the underlying cause of the nerve compression. Some interesting treatment options like autogenous saphanous vein wrapping of the Median nerve at wrist for recurrent compressive neuropathy also find a mention. The Ulnar nerve at the elbow level is relieved of compression by either anterior transposition or medial epicondylectomy. The treatment options include vocational or occupational counseling, wrist splint and other splints, over-the-counter pain medication or prescription drugs, Surgery and Physical therapy. Taking safety measures to compensate for loss of sensation is of vital importance.

The pathophysiology of Compression Neuropathy is a chronic blunt injury to the peripheral nerve resulting in microvascular ischemic changes, oedema, dislocation of the nodes of Ranvier, and structural alterations in the membranes at the organelle levels in both the myelin sheath and the axon. Focal segmental demyelination is a constant feature. Complete recovery of function after surgical decompression represents remyelination. Incomplete recovery in more chronic and severe cases is due to Wallerian degeneration of the axons and permanent fibrotic changes in the neuro-muscular junctions that prevent reinnervation.

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