This document discusses the anatomy, evaluation, and treatment of various types of hand and facial injuries. It provides details on: - The anatomy of bones, muscles, tendons and nerves in the hand. - Principles of evaluating hand injuries which include examining the skin, circulation, tendons, nerves and bones/joints. - Treatment approaches for different types of injuries like tendon injuries, nerve injuries and replantation. - Causes, symptoms, clinical examination and treatment of soft tissue facial injuries including various wound closure techniques.

1. Hand Injury
Soft Tissue
Hossam Elkafrawi M.D.

2. • Hand injuries are common and account for 5-
10% of emergency department visits
nationwide
• Good physical examination skills, and
knowledge of indications for treatment are
indispensable for the emergency physician.

3. Anatomy
Bony anatomy:
• The wrist is composed of 8 carpal bones arranged
in 2 rows of 4. The flexor retinaculum together
with the carpal bones forms the carpal tunnel
• The metacarpal bones articulate with the wrist at
the carpometacarpal (CMC) joints
• The thumb has only 1 interphalangeal (IP) joint,
while the rest of the digits have proximal
interphalangeal (PIP) and distal interphalangeal
(DIP) joints.

5. • Intrinsic muscles of the hand:
• They can be divided into 4 groups as follows:
• The thenar eminence is formed by the extensor pollicis brevis and the 3
short thenar muscles: the abductor pollicis brevis, flexor pollicis brevis,
and opponens pollicis. innervated by the recurrent branch of the median
nerve. The superficial location of this branch renders it vulnerable to
seemingly trivial trauma to the thenar eminence.
• hypothenar (little finger),
• Lumbricals: flex the digits at the MCP joints and extend the IP joints. They
place the fingers in the writing position.
• Seven interosseous muscles are located between the metacarpal bones; 3
are palmar and 4 are dorsal. The palmar interossei adduct, while the
dorsal interossei abduct.
• The adductor pollicis. It is innervated by the ulnar nerve.

6. Evaluation of inuries
• Skin
• Circulation
• Tendons
• Nerves
• Bones and joints

7. Principle of treatment
• Anaesthesia
• Tourniquet
• Careful wound toilet.
• Splints and dressing
• Avoidance of swelling and stiffness

8. • Tidy hand Injuries
• Untidy Hand Injuries
• Undeterminable hand injuries

9. Skin loss
• Finger tip injuries
• Skin loss without exposure of deeper
structures
• Skin loss with exposure to deeper structures

17. Tendon injuries
• Early :
– Primary repair
• Delayed:
– Secondary Repair
– Tendon grafts
– Tendon transferes

18. Anatomy of the flexor tendons
• Superficialis tendons maintain constant
arrangement in the distal wrist:
– the tendons to the middle and ring fingers
lie palmar to those of the index and little
fingers.
• Profundus tendons travel in a single
layer deep to the superficialis tendons in
the wrist and the palm.

19. Anatomy of the
flexor tendons
• The lumbrical
muscles originate
from the FDP
distal to the
carpal tunnel.

20. Anatomy of the
flexor tendons
•Over the proximal
phalanx, the FDS
tendon splits into
two slips around the
FDP tendon and then
reunite deep to it
with decussation of
half of the fibers
(Camper’s chiasma).

21. • The pulleys of the
fingers consists of a
palmar aponeurosis
pulley, five annular
pulleys and three
cruciate pulleys.
• The annular pulleys
A2 and A 4 are crucial
for normal digital
function, they
prevent tendon
bowstringing and
provide optimal
joint flexion.

22. Verdan’sflexor tendonzones
• The actual level of
tendon injury in
relation to its
surrounding
tissue is of
significance in
estimating the
prognosis.
• No man’s land of
Bunnell.

23. Diagnosis of flexor tendon injury:

24. Surgical repair of flexor tendon:
1- Primary. (within 24 hours).
2- Delayed primary. (1-14 days).
3- Early secondary. (2-5 weeks).
4- Late secondary. (> 5 weeks).
5- Tendon grafts.
6- Tenolysis.

25. 1- Adequate anaesthesia.
2- complete aseptic technique.
3- Bloodless field. (tourniquet).
4- Good magnification.
5- Atraumatic technique.
6- Adequate exposure.
Repair of flexor tendons should be carried
out under optimal conditions:

26. Retrieval of flexor tendons:
Multiple maneuvers:
• Blind retrieval.
• Catheter retrieval.
• Tendon retrievers.
• Endoscopy.

27. Suture techniques:
• Any suture technique should include:
1- Core suture.
2- Circumferential epitenon suture.
• Many suture techniques for flexor tendon
repairs have been advocated; Bunnell,
modified Kessler-Tajima, augmented
Becker, Strickland, Kleinert, Pulvertaft
and epitenon-first.

28. Suture techniques:
• Modified Kessler

29. Suture Techniques
• Kleinert suture

30. Suture Techniques
• Strickland

31. Postoperative mobilization
• There are three methods of postoperative
motion:
1- Controlled passive motion. (Duran & Houser)
Non-compliant.
2- Controlled active extension. (Kleinert)
Compliant patients
3- Early active motion. (Chow)
Highly motivated patient.

32. • Duran &Houser
Postoperative mobilization

33. Postoperative mobilization
• Kleinert

34. Early Active Mobilization
• This is carried out under strict supervision of a
physiatrist then by the patient.
• The aim is to do selective 5 daily active FDP
and FDS flexions separately.
• This will help the differential function of the
separate muscles.

35. Tendon Grafts
• 2-staged (tendon spacers)
• Intercalary

36. Tendon Transfers
• Superficialis to flexor pollicis
• Transfer sets in radial and posterior
interosseous nerve injuries.
• Opponens plasty

41. Nerve iujuries
• Primary repair
• Delayed repair

47. Vascular injuries
• Re-vasucularization
• Replantation

51. Replantation
• Replantation is the reattachment of a
completely detached body part.
• Fingers and thumbs are the most common
but the Hands, ear, scalp, hand, arm and penis
have all been replanted.

56. • Generally replantation involves restoring blood
flow, restoring the bony skeleton and connecting
tendons and nerves as required.
• Initially, success was defined in terms of a survival
of the amputated part alone.
• However, as more experience was gained in this
field, surgeons began to understand that survival
of the amputated piece was not enough
• In this way, functional demands of the amputated
specimen became paramount in guiding which
amputated pieces should and should not be
replanted.

61. Facial Injuries

62. • soft tissue injuries
• facial bone fractures

63. Etiology of Facial Injuries
• Road Traffic Accidents
• Interpersonel violence
• Sport accidents
• Home accidents
• Occupational accidents
• Shot-gun injuries

64. Emergency Treatment
• Airway
• Cleaning of blood, vomit and theet from inside of mouth with fingers
• Aspiration of blood, saliva, and gastric contents
• Early Intubation or Tracheostomy
• Bleeding
• Direct pressure on the wound
• Tying of bleeding vessels(Facial, superficial temporal, angular or ext.
carotid)
• Anterior-posterior nasal packing
• Circulation
• Evaluate Associated Injuries ( cervical vertebrea, skull base, intracranial,
thoracal, intraabdominal)
• Diagnosis and treatment of facial injuries

65. Indications of Tracheostomy
• Panfacial fracures(combined mandible, maxilla and nasal
fractures)
• The multiply fractured mandible with significant swelling of
the neck and floor of the mouth
• Patients who require prolonged intermaxillary fixation who
have significant head or chest injuries
• Possibility of prolonged postop. airway problems
• Severe facial and neck edema resulting from soft tissue
injuries such as severe facial burns
• Unrelieved obstruction of airway in the region of larynx or the
hypopharynx

66. Clear Airway and provide patent airway

67. Soft tissue Injuries
• Abrasion
• Contusion (with or without hematoma)
• Laceration(most common form of facial injury)
• Avulsion
• Puncture
• Accidental Tattoo
• Retained Foreign Bodies

68. Symptom and Signs
• Soft tissue Injury
• Swelling
• Pain or localized tenderness
• Crepitation from areas of
underlying bone fracture
• Hypostesia and paralysis in the
distribution of specific nerve
• Malocclusion
Class I :Normal oclusion
Class II :Retrognathi
Class III :Prognathi
• Visual disturbance
• Diplopia or decrease in vision
• Facial asimmetry, deformity
• Obstructed respiration
• Lacerations inside of mouth
• Ecchymosis
• Bleeding

69. Clinical Examination-I
• Evaluation for symmetry and deformity
• Inspection of face ( comparing 2 sides)
• Palpation of all bony surfaces in an orderly manner
(sup. and inf. orbital rims, nose, the brows, the
zygomatic arches, malar eminence, border of
mandible)
• Inspection of intraoral area for lacerations and
abnormalities of the dentition
• Palpation of dental arches for abnormal mobility

70. Clinical Examination-II
• Maxillary and mandibular dental arches are carefully
visualized and palpated for bone irregularity, bruise,
hematoma, tenderness or crepitus
• Sensory and motor nerve functions in the facial area
evaluated
• Extraocular movements and muscle of facial
expression must be examined
• Globe functions (pupillary size and symmetry, globe
excursion, eyelid excursion, double vision and visual
loss) and fundoscopic examination

71. Treatment of Soft Tissue Injuries
• Primary closure
• Delayed primary closure
• Secondary healing
• Tertiary healing (skin grafts, flaps)

72. Wound Closure-I
• The time lapse between injury and repair is
important in terms of the possibility of infection and
the choice of repair techniques
• Primary closure is treatment of choice
• It is applied immediately after the trauma if the
wound is sharp and clean
• debridement, excision of a millimeter or two of the
wound edge
• The wound edges is approximated with sutures

73. Wound Closure-II
• The contused, dirty and heavy contamined
wounds are not closed by primaryly
• Shotgun wounds, animal and human bites are
not closed primarly as well

74. Delayed Primary Closure
• The wound must be prepared with
debridment and dressing
Cleaning
Irrigation
Debridment
• The wound can be closed primarly after 24-48
hours, If it is clean and free of devitalized
tissue

75. Secondary Closure
• If the wound is heavily contamined and
infected, contains necrotic and devital tissues
after 48 hours, The wound can be closed after
cleaning of the wound or can be left to
secondary healing
• Secondary healing occurs with secondary
wound contracture and marginal
epithelization