pa4ortho
08-26-09, 11:01
injury to fingers are a common serious Orthopedic problem. most are simple laceration injuries. the next most common are tendon injuries. amputation vs repair is the 3rd most common presenting injury. subungual hematoma is also common.
I will use a case study to highlight treatment options.
a 38 yo male pinched his finger in a hinge degloving all tissue to the bone circumfrentialy distal to the germinal matrex(0-2mm proximal to the base of the nail. the nail is missing. 3-4mm of bone is exposed. a total of 6cc 0.25 marcaine is injected on the radial and ulnar side of the base of the finger. WAIT 5-10min for the latent period to pass. irigate the finger with what you have saline , tap water, filtered water, bottled water etc... clean the skin and setup a sterile feild apply a tourniquet with a rubber penrose drain to the base of the finger or you will get to apreciate small vessel arterial spray. you can make a good tourniquet by putting a glove finger on, cutting the tip and rolling it up on the finger like a ring. next prepare the soft tissue for closure. shape the tissue into a "fish mouth" by removing a wedge on both sides. the wedge is aprox 2mm(dorsal volar) x 4mm. (distal proximal) if you don't remove this wedge the finger will have corners instead of a nice round shape. when using the scalpel to do this, cut perpendicular to the skin. do not undermine the blood supply or leave to much tissue to close. next free up the tissues volar by spreading with small scissors between the bone and the pad of the finger 5-7mm. remove the bone squarely with a small rongour. (ebay) or wire cutters (not as good) smooth all corners with the sides of the rongour or a small file. the bone is removed untill the soft tissues can be closed without undue tension. in this patient the bone is removed to a level 1/2 the distance of the fingernail. if the germinal matrex is destroyed leave a 5mm nub of distal phalanx. the next level is the distal IP joint. this is easy. as you just cut the ligaments and remove the distal phalanx. the middle phalanx is already smooth on the joint surface. close with 3-0 prolene (blue easy to find later for removal) or nylon. usually done with simple interupted sutures. I prefer 2 narrow horizontal mattress sutures across the tip and simple on the sides. alternatively bend a small sewing needle when its red hot over a round object and close with small fish line. dress with non stick dressing, placing a small spacer (apaptic, xeroform, thin strip of plastic or rubber glove ) under the eponicial sp? fold and wrap loose with gauze thick enough to splint the finger. remove with peroxide in 2-3 days and re dress. 10-14 days for sutures removal. leave them longer if needed. don't debride any dry black tissue. let it heal under the unviable crust untill it falls off. be patient. start active and passive range of motion at 2 -4 weeks. prolonged stretches 1min works well. also alternating gental active extention and flexion every 10sec while applying passive flexion or extention. pad untill any hyper sensitivity is resolved.
practice on a small chicken leg
the above is a simple procedure that anyone with moderate skill can accomplish with some practice on the chicken leg.
further skilled operators can transect the nerves on both sides to keep them out of the scar tissue, to minimize hypersensitivity. sutures in flexor tendons to prevent retraction on more proximal amputations will improve function
subungual hematoma is painfull but easy to tx.
a red hot paper clip makes a hole in the nail for the blood to drain. alternatively spinning a hypodermic needle will drill through the nail an opthalmic cautery works the easiest .
extensor tendons can be repaired with some skill under local anesthesia. dont be afraid to extend the wound into an L shape or a lightning bolt shape. cut perpendicular to the skin. don't make the point side of the corner less than 90deg or you risk the blood supply. grasp tendons gently and pull them together. pin them in place with hypo needles like your bug collection. by flexing the wrist they pull easier. 3-0 nylon sew starting off center on the cut end of a tendon. go into the tendons deeper than the width of the tendons at least. the needle is then directed out the side of the tendon you were off center closest to. the suture is layed over the top of the tendon the needle is inserted directly oposite where you exited the 1st pass. exit the needle out the cut end of the tendon offset on the oposite side. duplicate this paternal on the oposite cut end. the knot will be burried in the cut ends of the tendons when they are aproximated. simple sutures will just rip out. you have to lasso the tendons as described above. splint in extention for 4weeks. then start gentle active range of motion with splinting between motion untill 6weeks then active and passive motion. 8-10 weeks full use.
with the amputation and the tendon repair 7-10 days of standard abo tx is a good idea. -1gm ancef iv if available and d/c with keflex 500mg qid
-500mg bid your favorite quinolone(cipro, levaquin, moxy) po rather than ancef iv. great rapid broad spectrum good bone/soft tissue penetration.
with the amputation there is a lifelong risk of osteomylitis. it is low as you have removed the exposed bone. any s/s infection or chronic deep bone pain warents further investigation vs further amputation.
pa4ortho
I will use a case study to highlight treatment options.
a 38 yo male pinched his finger in a hinge degloving all tissue to the bone circumfrentialy distal to the germinal matrex(0-2mm proximal to the base of the nail. the nail is missing. 3-4mm of bone is exposed. a total of 6cc 0.25 marcaine is injected on the radial and ulnar side of the base of the finger. WAIT 5-10min for the latent period to pass. irigate the finger with what you have saline , tap water, filtered water, bottled water etc... clean the skin and setup a sterile feild apply a tourniquet with a rubber penrose drain to the base of the finger or you will get to apreciate small vessel arterial spray. you can make a good tourniquet by putting a glove finger on, cutting the tip and rolling it up on the finger like a ring. next prepare the soft tissue for closure. shape the tissue into a "fish mouth" by removing a wedge on both sides. the wedge is aprox 2mm(dorsal volar) x 4mm. (distal proximal) if you don't remove this wedge the finger will have corners instead of a nice round shape. when using the scalpel to do this, cut perpendicular to the skin. do not undermine the blood supply or leave to much tissue to close. next free up the tissues volar by spreading with small scissors between the bone and the pad of the finger 5-7mm. remove the bone squarely with a small rongour. (ebay) or wire cutters (not as good) smooth all corners with the sides of the rongour or a small file. the bone is removed untill the soft tissues can be closed without undue tension. in this patient the bone is removed to a level 1/2 the distance of the fingernail. if the germinal matrex is destroyed leave a 5mm nub of distal phalanx. the next level is the distal IP joint. this is easy. as you just cut the ligaments and remove the distal phalanx. the middle phalanx is already smooth on the joint surface. close with 3-0 prolene (blue easy to find later for removal) or nylon. usually done with simple interupted sutures. I prefer 2 narrow horizontal mattress sutures across the tip and simple on the sides. alternatively bend a small sewing needle when its red hot over a round object and close with small fish line. dress with non stick dressing, placing a small spacer (apaptic, xeroform, thin strip of plastic or rubber glove ) under the eponicial sp? fold and wrap loose with gauze thick enough to splint the finger. remove with peroxide in 2-3 days and re dress. 10-14 days for sutures removal. leave them longer if needed. don't debride any dry black tissue. let it heal under the unviable crust untill it falls off. be patient. start active and passive range of motion at 2 -4 weeks. prolonged stretches 1min works well. also alternating gental active extention and flexion every 10sec while applying passive flexion or extention. pad untill any hyper sensitivity is resolved.
practice on a small chicken leg
the above is a simple procedure that anyone with moderate skill can accomplish with some practice on the chicken leg.
further skilled operators can transect the nerves on both sides to keep them out of the scar tissue, to minimize hypersensitivity. sutures in flexor tendons to prevent retraction on more proximal amputations will improve function
subungual hematoma is painfull but easy to tx.
a red hot paper clip makes a hole in the nail for the blood to drain. alternatively spinning a hypodermic needle will drill through the nail an opthalmic cautery works the easiest .
extensor tendons can be repaired with some skill under local anesthesia. dont be afraid to extend the wound into an L shape or a lightning bolt shape. cut perpendicular to the skin. don't make the point side of the corner less than 90deg or you risk the blood supply. grasp tendons gently and pull them together. pin them in place with hypo needles like your bug collection. by flexing the wrist they pull easier. 3-0 nylon sew starting off center on the cut end of a tendon. go into the tendons deeper than the width of the tendons at least. the needle is then directed out the side of the tendon you were off center closest to. the suture is layed over the top of the tendon the needle is inserted directly oposite where you exited the 1st pass. exit the needle out the cut end of the tendon offset on the oposite side. duplicate this paternal on the oposite cut end. the knot will be burried in the cut ends of the tendons when they are aproximated. simple sutures will just rip out. you have to lasso the tendons as described above. splint in extention for 4weeks. then start gentle active range of motion with splinting between motion untill 6weeks then active and passive motion. 8-10 weeks full use.
with the amputation and the tendon repair 7-10 days of standard abo tx is a good idea. -1gm ancef iv if available and d/c with keflex 500mg qid
-500mg bid your favorite quinolone(cipro, levaquin, moxy) po rather than ancef iv. great rapid broad spectrum good bone/soft tissue penetration.
with the amputation there is a lifelong risk of osteomylitis. it is low as you have removed the exposed bone. any s/s infection or chronic deep bone pain warents further investigation vs further amputation.
pa4ortho