All hand injuries, regardless of superficiality, may result in crippling loss of function if treatment is inadequate or mishandled. The essential elements of diagnosis, examination, approach to therapy and after-care are constant. The major difference between an injury requiring hospitalization and one amenable to outpatient management is the extent of the trauma. This article reviews the major outpatient injuries with respect to method of management, choice of definitive procedure, and preservation of function

Masters, Frank W.

Robinson, David W.

English

EngagedScholarship @ Cleveland State University

Cleveland State University
EngagedScholarship@CSU
Cleveland State Law Review Law Journals
1964
Outpatient Injuries of the Hand
Frank W. Masters
David W. Robinson
Follow this and additional works at: https://engagedscholarship.csuohio.edu/clevstlrev
Part of the Medical Jurisprudence Commons
How does access to this work benefit you? Let us know!
This Article is brought to you for free and open access by the Law Journals at EngagedScholarship@CSU. It has been accepted for inclusion in
Cleveland State Law Review by an authorized editor of EngagedScholarship@CSU. For more information, please contact library.es@csuohio.edu.
Recommended Citation
Frank W. Masters & David W. Robinson, Outpatient Injuries of the Hand, 13 Clev.-Marshall L. Rev. 473 (1964)
Outpatient Injuries of the Hand
Frank W. Masters* and David W. Robinson*
NJURY OF THE HAND is the most frequent of all compensable
accidents. Varying from simple abrasion to extensive avul-
sion, and combined with loss of function and earning power, the
specialized problems of hand injury have created an entirely
new field of surgical reconstruction and rehabilitation.
For every major injury that requires extensive and often
staged reconstruction, there are multiple lesser accidents which
are suitable for outpatient management. Such trauma does not
require elaborate surgical facilities for definitive care, and a
maximum of function can be obtained with a minimum of com-
plication and loss of time. These "minor" injuries include various
soft tissue defects which are primarily limited to the digits.
When structural elements such as tendon or bone are involved,
the injury cannot be considered as minor or as an outpatient
type of trauma, since permanent loss of function may follow ideal
therapy.
Here the term "minor" injury is a misnomer. All hand in-
juries, regardless of superficiality, may result in crippling loss of
function if treatment is inadequate or mishandled. The essen-
tial elements of diagnosis, examination, approach to therapy and
after-care are constant. The major difference between an injury
requiring hospitalization and one amenable to outpatient man-
agement is the extent of the trauma. This article reviews the
major outpatient injuries with respect to method of manage-
ment, choice of definitive procedure, and preservation of func-
tion.
Injury to the Fingernail and Matrix
Subungual hematomaI is an extremely common injury
usually resulting from a "pinch" or "smash." The distal phalanx
2
is swollen and tender, with discoloration beneath the nail. This
* M.D.; of the Department of Surgery, Section of Plastic Surgery, University
of Kansas Medical Center, Kansas City, Kansas.
[Note: This is a digest by the Editors of this Law Review, of a medical
article by the authors, in the July 1962 issue of G.P., as approved by the
authors and the latter, and with permission. It has been simplified, for use
by attorneys.]
1 A collection of blood under the nail.
2 Last joint of finger.
1Published by EngagedScholarship@CSU, 1964
13 CLEV-MAR. L. R. (3)
is accompanied by a deep, throbbing pain, made worse by de-
pendency. Therapy consists of evacuation of the hematoma and
provision of a pathway for drainage to prevent re-formation of
the clot.
Various methods of management have been described. A
small hole can be drilled through the nail with a scalpel blade
or with a small dental drill, but the simplest procedure is to use
the heated point of a paper clip. This method is quick, virtually
painless, and requires no pressure to penetrate the thickness of
the nail.
The major complication of this therapy is infection. This can
be prevented by careful pre-operative cleansing and simple cov-
erage of the drainage site after evacuation.
Partial avulsions of the nail are easily treated as outpatient
injuries. Therapy depends upon the direction of the avulsion.
If the distal part of the nail is torn free, it should be replaced
in its bed and splinted in place with a simple adhesive dressing.
If, however, the partial avulsion occurs at the base of the nail
and does not involve the nail matrix,3 the loose segment should
be trimmed away to the adherent area, under local anesthesia,
and the nail base dressed with a non-adherent dressing to pro-
mote epithelization.1 If the detached nail is replaced without
debridement,5 the devitalized fragment acts as a foreign body and
Figure 1. Injury to nail matrix-The
repair of the avulsed nail matrix is Figure 2. Laceration without deepfacilitated by mattress sutures at the damage-Z-plasty at the flexion
base. The matrix must be replaced creases-will prevent future contrac-
to prevent osteomyelitis of the un- ture of a linear laceration across thederlying distal phalanx, creases.
3 Nail bed.
4 Healing with skin.
5 The surgical removal of lacerated, devitalized, or contaminated tissue.
Sept., 1964
2https://engagedscholarship.csuohio.edu/clevstlrev/vol13/iss3/7
INJURIES OF HAND
the subsequent tissue reaction may produce a paronychia-type
infection.'
When the nail matrix is avulsed, it should be replaced and
sutured beneath the eponychial7 covering (Figure 1). Since
the matrix is fused with the dorsal periosteum8 of the distal
phalanx, its avulsion is a possible source of osteomyelitis 9 and
destruction of the bone. The avulsed matrix can be easily re-
stored to its anatomic location by using two mattress sutures of
fine silk or nylon and a non-adherent pressure dressing applied
to aid in immobilization.
Lacerations
The repair of simple lacerations presents no difficulty unless
the flexion creases are crossed. Even extensive lacerations that
do not involve tendons still fall into the category of "outpatient"
injury. The immediate repair should consist first of a thorough
cleansing with bland soap and water. No chemical antiseptic
should be used. This is followed by a careful debridement, par-
ticularly of nonviable muscles. A meticulous repair is then done,
designed to eliminate dead space. Immobilization to put the hand
at rest is essential to promote rapid healing and facilitate return
to active function. If there is any concern about identification of
deeper structures, a bloodless field is necessary and a pneumatic
tourniquet is mandatory.
When the dorsal or volar 1° flexion creases are crossed by a
wound and the laceration is repaired by side-to-side approxima-
tion at the flexion crease, contracture and loss of function are
inevitable unless the direction of the laceration is altered at the
level of the flexion crease. The most satisfactory method of
altering the line of contracture is by simple Z-plasty wherever
the line of laceration crosses the flexion crease (Figure 2). This
maneuver breaks up the line of contracture by staggering the
line of closure. However, if the contracture has not had enough
6 Inflammation of the tissues adjacent to the nail of a finger, usually ac-
companied by infection and pus formation.
7 The thin skin adherent to the nail at its proximal portion.
8 Membrane of connective tissue that closely invests all bones except at the
articular surfaces.
9 An infectious, inflammatory disease of bone marked by local death and
separation of tissue.
10 Relating to the palm of the hand.
3Published by EngagedScholarship@CSU, 1964
13 CLEV-MAR. L. R. (3)
time to produce fibrotic"i joint changes, it, too, can be corrected
by Z-plasty as shown in Figures 3A and 3B. The majority of
such reconstructive procedures can be prevented by careful re-
pair of the original wound including preservation of the integrity
of the flexion crease.
Figure 3A. A linear laceration of the Figure 3B. The flexion contracture
index finger of an 18-year-old girl can be released by Z-plasty but
resulted in contracture when re- could have been prevented.
paired in a straight line.
Digital Nerve Repair
Digital nerve injury frequently complicates simple lacera-
tions of the fingers. This diagnosis may be missed unless a care-
ful sensory examination is an integral part of the evaluation of
any wound. The resulting loss of function can be disabling if a
painful neuroma 12 develops at the site of nerve injury.
Digital nerve repair as a primary procedure does not re-
quire elaborate surgical facilities. A 6-0 eye silk is the only
specialized equipment needed. Under local anesthesia, with
hemostasisl 3 secured by a rubber band tourniquet-at the base of
the finger, end-to-end repair of the digital nerve can be readily
performed to the level of the distal flexion crease. The nerve
ends must not be grasped with instruments but handled very
11 Formation of fibrous tissue.
12 A tumor or mass growing from a nerve and usually consisting of nerve
fibers.
13 Arrest of bleeding.
Sept., 1964
4https://engagedscholarship.csuohio.edu/clevstlrev/vol13/iss3/7
INJURIES OF HAND
gently, using only fingers and the suture needle. The ends should
be brought accurately together without torsion or tension and,
if length permits, trimmed with a sharp blade. Perineural14
sutures holding the two ends of the nerve in accurate approxima-
tion will produce uniformly good results. The return of sensa-
tion may be prolonged, since the process of nerve regeneration
may take several weeks or months depending upon the location
of the injury. When the nerve is divided proximal to the digit,
outpatient management should not be considered.
Amputation
Partial or complete amputations of the digits may lend
themselves well to outpatient management, particularly when
soft tissue alone is involved. The partial amputation produces
the more complex problem of definitive management because the
vascular supply of the flap is the sine qua non of survival.
Because the normal hand has an abundant supply of blood,
arterial insufficiency is unusual and loss of arterial function is
well tolerated. Venous congestion, however, almost always pro-
duces necrosis 15 in varying amounts. The common situations
which predispose to venous congestion are crush injuries and
retrograde flaps16 when the pedicle 17 is situated distal to the nor-
mal pathways of venous return.
When cyanosis s and delayed capillary return are apparent
at the time of primary repair, the "take a chance" attitude of
"sew it back and hope it survives" usually ends in disaster.
These congested flaps should be totally removed. If they are
not crushed, they can be defatted 19 and the skin can be replaced
as a primary full-thickness skin graft. If congestion is evident
after a crush injury, the flap should be discarded and the defect
either closed primarily or resurfaced with a split-thickness skin
graft. Such injuries, when limited to a single digit, do not re-
quire elaborate surgical facilities. In such cases, outpatient man-
agement is the rule rather than the exception.
The management of a complete amputation varies with the
14 The connective-tissue sheath that surrounds a bundle of nerve fibers.
15 Localized death of living tissue.
16 Mass of soft tissue having a single attachment to the body.
17 The point of attachment of flap to body.
18 Bluish or purplish discoloration due to deficient oxygenation of the blood.
19 Removal of subcutaneous fat.
5Published by EngagedScholarship@CSU, 1964
13 CLEV-MAR. L. R. (3)
level of injury and the structures involved. Length should be
preserved where possible, particularly if the thumb is injured.
The very young person has an amazing tolerance for this kind
of trauma and adapts readily to a defect which would produce
a functional deficit in the adult.
When digital amputation involves the distal phalanx, the
level of injury determines the management. If the tendon in-
sertions are not involved, length should be preserved. Even
though resection of bone will facilitate closure, it is preferable
to preserve the functional length of the distal phalanx by saving
the bone for length and applying a skin graft to the avulsed area.
This technique is shown in Figures 4A-4D.
Figure 4A. A fingertip amputation Figure 4C. A tie-over bolus
following a crushing injury in an dressing is applied to maintain
automobile door. pressure on the graft.
Figure 4B. After careful cleans-
ing and debridement, the ampu-
tation site is resurfaced with a
split-thickness skin graft to pre-
serve length of the digit.
Figure 4D. Postoperative appear-
ance 10 days after repair.
Sept., 1964
6https://engagedscholarship.csuohio.edu/clevstlrev/vol13/iss3/7
INJURIES OF HAND
If a small amount of bone is exposed, but the insertions of
the flexor20 and extensor 2 ' tendons are still intact, the bone
should be rongeured 2 - to smooth the bony phalanx. Here, again,
length is maintained by using a split-thickness skin graft for im-
mediate closure of the wound (Figure 5).
If amputation involves the extensor tendon insertion, the
remainder of the distal phalanx should be sacrificed because a
mallet finger is inevitable if the unopposed flexor profundus 23 is
allowed to act. When the entire distal phalanx requires re-
section, the cartilage and condyles24 should be removed and the
distal end shaped in a tapering fashion to allow for greatest
function. Under no circumstances, however, should the closure
be reinforced by suture of the two tendon ends across the re-
sected end of the bone. Such a technique will produce an ex-
tremely painful stump and markedly limit the function of the
finger.
The soft tissue closure of an amputation stump should be
tailored to give adequate coverage over the end of the bone for
a good pad without "dog ears" or tightness. This technique is
shown in Figure 6.
/. /
SMOOTH SPLIT.T H IKNICEIS STENT
BONE UKIN GRAFT DRESSING
Figure 5. Fingertip amputation-The
split-thickness skin graft technique
is the best method of maintaining
the length of an amputated finger-
tip even though bone is exposed. If
the bone is rongeured smooth, the
graft will "take" directly over the
bone narrow cavity.
Figure 6. Closure of amputation-
When the level of amputation in-
volves the extensor tendon insertion,
the soft tissue closure of the ampu-
tation stump should be tailored to
give adequate coverage without "dog
ears."
20 A muscle that serves to bend a limb.
21 A muscle serving to extend a limb.
22 An instrument for removing small pieces of bone.
23 The deep tendon to a finger.
24 An articular prominence of a bone; especially one of a pair like knuckles.
7Published by EngagedScholarship@CSU, 1964
13 CLEV-MAR. L. R. (3)
Burns
Among the most frequently burned areas of the body are
the hands. Children frequently grasp hot objects. Small, deep
burns of the hand are more serious than similar injuries of other
parts of the body. Careful diagnosis of the burned hand is most
important. The differentiation between partial 5 and full-thick-
ness 26 skin loss is essential for proper therapy, early healing,
and ultimate function.
Partial thickness burns will heal spontaneously if the physi-
cian will protect the remaining viable skin. Many methods of
management and a great variety of materials have been advo-
cated. Under controlled conditions, considerable latitude is al-
lowed. Partial thickness burns of the hand should be managed
by the closed technique. This includes immobilization in an oc-
clusive dressing with the individual fingers separated and the
hand in the position of function. Loose epithelium and the tops
of vesicles should be debrided and the hand cleansed with dilute
bland soap and water followed with saline. A dressing should be
applied carefully, utilizing fine mesh, nearly dry, grease gauze
to prevent adherence and destruction of young epithelium. This
is followed by a bulky pressure dressing separating the fingers.
Barring complications, second-degree burns of the hand will
heal spontaneously in 10 to 14 days. A carefully applied initial
dressing need not be changed for five to seven days after injury.
At the time of the first dressing change, extreme care should be
taken not to injure the newly formed epithelial covering. When
epithelization is complete, mobilization is begun to prevent fi-
brosis 27 and contracture.28 However, the epithelial surface must
be protected from excessive wear and tear until the covering is
mature; this may require two to three weeks.
When full-thickness burn occurs, the area involved must be
small if the injury is to be treated on an outpatient basis. Small,
deep burns of the hand are managed conservatively until the
area of loss is sharply demarcated and necrotic skin has
25 Second degree burn.
26 Third degree burn.
27 A condition marked by increase of interstitial fibrous tissue.
28 A permanent shortening (as of muscle, tendon, or scar tissue) producing
deformity or distortion.
Sept., 1964
8https://engagedscholarship.csuohio.edu/clevstlrev/vol13/iss3/7
INJURIES OF HAND
sloughed (Figure 7A). When granulation 29 has occurred, the
area must be resurfaced with split-thickness skin grafts as soon
as possible, not only to restore skin coverage, but also to prevent
fibrosis and loss of function (Figure 7B).
Figure 7A. A third-degree burn Figure 7B. Eight weeks after
of the index finger in a 30-year- early split-thickness skin grafting
old worker, to r e s u rf a c e the granulating
wound and prevent fibrosis.
29 One of the minute red granules of new capillaries formed on the surface
of a wound in healing.
9Published by EngagedScholarship@CSU, 1964


Outpatient Injuries of the Hand

Cleveland-Marshall College of Law

Cleveland State UniversityEngagedScholarship@CSUCleveland State Law Review Law Journals1964Outpatient Injuries of the HandFrank W. MastersDavid W. RobinsonFollow this and additional works at: https://engagedscholarship.csuohio.edu/clevstlrevPart of the Medical Jurisprudence CommonsHow does access to this work benefit you? Let us know!This Article is brought to you for free and open access by the Law Journals at EngagedScholarship@CSU. It has been accepted for inclusion inCleveland State Law Review by an authorized editor of EngagedScholarship@CSU. For more information, please contact library.es@csuohio.edu.Recommended CitationFrank W. Masters & David W. Robinson, Outpatient Injuries of the Hand, 13 Clev.-Marshall L. Rev. 473 (1964)Outpatient Injuries of the HandFrank W. Masters* and David W. Robinson*NJURY OF THE HAND is the most frequent of all compensableaccidents. Varying from simple abrasion to extensive avul-sion, and combined with loss of function and earning power, thespecialized problems of hand injury have created an entirelynew field of surgical reconstruction and rehabilitation.For every major injury that requires extensive and oftenstaged reconstruction, there are multiple lesser accidents whichare suitable for outpatient management. Such trauma does notrequire elaborate surgical facilities for definitive care, and amaximum of function can be obtained with a minimum of com-plication and loss of time. These "minor" injuries include varioussoft tissue defects which are primarily limited to the digits.When structural elements such as tendon or bone are involved,the injury cannot be considered as minor or as an outpatienttype of trauma, since permanent loss of function may follow idealtherapy.Here the term "minor" injury is a misnomer. All hand in-juries, regardless of superficiality, may result in crippling loss offunction if treatment is inadequate or mishandled. The essen-tial elements of diagnosis, examination, approach to therapy andafter-care are constant. The major difference between an injuryrequiring hospitalization and one amenable to outpatient man-agement is the extent of the trauma. This article reviews themajor outpatient injuries with respect to method of manage-ment, choice of definitive procedure, and preservation of func-tion.Injury to the Fingernail and MatrixSubungual hematomaI is an extremely common injuryusually resulting from a "pinch" or "smash." The distal phalanx2is swollen and tender, with discoloration beneath the nail. This* M.D.; of the Department of Surgery, Section of Plastic Surgery, Universityof Kansas Medical Center, Kansas City, Kansas.[Note: This is a digest by the Editors of this Law Review, of a medicalarticle by the authors, in the July 1962 issue of G.P., as approved by theauthors and the latter, and with permission. It has been simplified, for useby attorneys.]1 A collection of blood under the nail.2 Last joint of finger.1Published by EngagedScholarship@CSU, 196413 CLEV-MAR. L. R. (3)is accompanied by a deep, throbbing pain, made worse by de-pendency. Therapy consists of evacuation of the hematoma andprovision of a pathway for drainage to prevent re-formation ofthe clot.Various methods of management have been described. Asmall hole can be drilled through the nail with a scalpel bladeor with a small dental drill, but the simplest procedure is to usethe heated point of a paper clip. This method is quick, virtuallypainless, and requires no pressure to penetrate the thickness ofthe nail.The major complication of this therapy is infection. This canbe prevented by careful pre-operative cleansing and simple cov-erage of the drainage site after evacuation.Partial avulsions of the nail are easily treated as outpatientinjuries. Therapy depends upon the direction of the avulsion.If the distal part of the nail is torn free, it should be replacedin its bed and splinted in place with a simple adhesive dressing.If, however, the partial avulsion occurs at the base of the nailand does not involve the nail matrix,3 the loose segment shouldbe trimmed away to the adherent area, under local anesthesia,and the nail base dressed with a non-adherent dressing to pro-mote epithelization.1 If the detached nail is replaced withoutdebridement,5 the devitalized fragment acts as a foreign body andFigure 1. Injury to nail matrix-Therepair of the avulsed nail matrix is Figure 2. Laceration without deepfacilitated by mattress sutures at the damage-Z-plasty at the flexionbase. The matrix must be replaced creases-will prevent future contrac-to prevent osteomyelitis of the un- ture of a linear laceration across thederlying distal phalanx, creases.3 Nail bed.4 Healing with skin.5 The surgical removal of lacerated, devitalized, or contaminated tissue.Sept., 19642https://engagedscholarship.csuohio.edu/clevstlrev/vol13/iss3/7INJURIES OF HANDthe subsequent tissue reaction may produce a paronychia-typeinfection.'When the nail matrix is avulsed, it should be replaced andsutured beneath the eponychial7 covering (Figure 1). Sincethe matrix is fused with the dorsal periosteum8 of the distalphalanx, its avulsion is a possible source of osteomyelitis 9 anddestruction of the bone. The avulsed matrix can be easily re-stored to its anatomic location by using two mattress sutures offine silk or nylon and a non-adherent pressure dressing appliedto aid in immobilization.LacerationsThe repair of simple lacerations presents no difficulty unlessthe flexion creases are crossed. Even extensive lacerations thatdo not involve tendons still fall into the category of "outpatient"injury. The immediate repair should consist first of a thoroughcleansing with bland soap and water. No chemical antisepticshould be used. This is followed by a careful debridement, par-ticularly of nonviable muscles. A meticulous repair is then done,designed to eliminate dead space. Immobilization to put the handat rest is essential to promote rapid healing and facilitate returnto active function. If there is any concern about identification ofdeeper structures, a bloodless field is necessary and a pneumatictourniquet is mandatory.When the dorsal or volar 1° flexion creases are crossed by awound and the laceration is repaired by side-to-side approxima-tion at the flexion crease, contracture and loss of function areinevitable unless the direction of the laceration is altered at thelevel of the flexion crease. The most satisfactory method ofaltering the line of contracture is by simple Z-plasty whereverthe line of laceration crosses the flexion crease (Figure 2). Thismaneuver breaks up the line of contracture by staggering theline of closure. However, if the contracture has not had enough6 Inflammation of the tissues adjacent to the nail of a finger, usually ac-companied by infection and pus formation.7 The thin skin adherent to the nail at its proximal portion.8 Membrane of connective tissue that closely invests all bones except at thearticular surfaces.9 An infectious, inflammatory disease of bone marked by local death andseparation of tissue.10 Relating to the palm of the hand.3Published by EngagedScholarship@CSU, 196413 CLEV-MAR. L. R. (3)time to produce fibrotic"i joint changes, it, too, can be correctedby Z-plasty as shown in Figures 3A and 3B. The majority ofsuch reconstructive procedures can be prevented by careful re-pair of the original wound including preservation of the integrityof the flexion crease.Figure 3A. A linear laceration of the Figure 3B. The flexion contractureindex finger of an 18-year-old girl can be released by Z-plasty butresulted in contracture when re- could have been prevented.paired in a straight line.Digital Nerve RepairDigital nerve injury frequently complicates simple lacera-tions of the fingers. This diagnosis may be missed unless a care-ful sensory examination is an integral part of the evaluation ofany wound. The resulting loss of function can be disabling if apainful neuroma 12 develops at the site of nerve injury.Digital nerve repair as a primary procedure does not re-quire elaborate surgical facilities. A 6-0 eye silk is the onlyspecialized equipment needed. Under local anesthesia, withhemostasisl 3 secured by a rubber band tourniquet-at the base ofthe finger, end-to-end repair of the digital nerve can be readilyperformed to the level of the distal flexion crease. The nerveends must not be grasped with instruments but handled very11 Formation of fibrous tissue.12 A tumor or mass growing from a nerve and usually consisting of nervefibers.13 Arrest of bleeding.Sept., 19644https://engagedscholarship.csuohio.edu/clevstlrev/vol13/iss3/7INJURIES OF HANDgently, using only fingers and the suture needle. The ends shouldbe brought accurately together without torsion or tension and,if length permits, trimmed with a sharp blade. Perineural14sutures holding the two ends of the nerve in accurate approxima-tion will produce uniformly good results. The return of sensa-tion may be prolonged, since the process of nerve regenerationmay take several weeks or months depending upon the locationof the injury. When the nerve is divided proximal to the digit,outpatient management should not be considered.AmputationPartial or complete amputations of the digits may lendthemselves well to outpatient management, particularly whensoft tissue alone is involved. The partial amputation producesthe more complex problem of definitive management because thevascular supply of the flap is the sine qua non of survival.Because the normal hand has an abundant supply of blood,arterial insufficiency is unusual and loss of arterial function iswell tolerated. Venous congestion, however, almost always pro-duces necrosis 15 in varying amounts. The common situationswhich predispose to venous congestion are crush injuries andretrograde flaps16 when the pedicle 17 is situated distal to the nor-mal pathways of venous return.When cyanosis s and delayed capillary return are apparentat the time of primary repair, the "take a chance" attitude of"sew it back and hope it survives" usually ends in disaster.These congested flaps should be totally removed. If they arenot crushed, they can be defatted 19 and the skin can be replacedas a primary full-thickness skin graft. If congestion is evidentafter a crush injury, the flap should be discarded and the defecteither closed primarily or resurfaced with a split-thickness skingraft. Such injuries, when limited to a single digit, do not re-quire elaborate surgical facilities. In such cases, outpatient man-agement is the rule rather than the exception.The management of a complete amputation varies with the14 The connective-tissue sheath that surrounds a bundle of nerve fibers.15 Localized death of living tissue.16 Mass of soft tissue having a single attachment to the body.17 The point of attachment of flap to body.18 Bluish or purplish discoloration due to deficient oxygenation of the blood.19 Removal of subcutaneous fat.5Published by EngagedScholarship@CSU, 196413 CLEV-MAR. L. R. (3)level of injury and the structures involved. Length should bepreserved where possible, particularly if the thumb is injured.The very young person has an amazing tolerance for this kindof trauma and adapts readily to a defect which would producea functional deficit in the adult.When digital amputation involves the distal phalanx, thelevel of injury determines the management. If the tendon in-sertions are not involved, length should be preserved. Eventhough resection of bone will facilitate closure, it is preferableto preserve the functional length of the distal phalanx by savingthe bone for length and applying a skin graft to the avulsed area.This technique is shown in Figures 4A-4D.Figure 4A. A fingertip amputation Figure 4C. A tie-over bolusfollowing a crushing injury in an dressing is applied to maintainautomobile door. pressure on the graft.Figure 4B. After careful cleans-ing and debridement, the ampu-tation site is resurfaced with asplit-thickness skin graft to pre-serve length of the digit.Figure 4D. Postoperative appear-ance 10 days after repair.Sept., 19646https://engagedscholarship.csuohio.edu/clevstlrev/vol13/iss3/7INJURIES OF HANDIf a small amount of bone is exposed, but the insertions ofthe flexor20 and extensor 2 ' tendons are still intact, the boneshould be rongeured 2 - to smooth the bony phalanx. Here, again,length is maintained by using a split-thickness skin graft for im-mediate closure of the wound (Figure 5).If amputation involves the extensor tendon insertion, theremainder of the distal phalanx should be sacrificed because amallet finger is inevitable if the unopposed flexor profundus 23 isallowed to act. When the entire distal phalanx requires re-section, the cartilage and condyles24 should be removed and thedistal end shaped in a tapering fashion to allow for greatestfunction. Under no circumstances, however, should the closurebe reinforced by suture of the two tendon ends across the re-sected end of the bone. Such a technique will produce an ex-tremely painful stump and markedly limit the function of thefinger.The soft tissue closure of an amputation stump should betailored to give adequate coverage over the end of the bone fora good pad without "dog ears" or tightness. This technique isshown in Figure 6./. /SMOOTH SPLIT.T H IKNICEIS STENTBONE UKIN GRAFT DRESSINGFigure 5. Fingertip amputation-Thesplit-thickness skin graft techniqueis the best method of maintainingthe length of an amputated finger-tip even though bone is exposed. Ifthe bone is rongeured smooth, thegraft will "take" directly over thebone narrow cavity.Figure 6. Closure of amputation-When the level of amputation in-volves the extensor tendon insertion,the soft tissue closure of the ampu-tation stump should be tailored togive adequate coverage without "dogears."20 A muscle that serves to bend a limb.21 A muscle serving to extend a limb.22 An instrument for removing small pieces of bone.23 The deep tendon to a finger.24 An articular prominence of a bone; especially one of a pair like knuckles.7Published by EngagedScholarship@CSU, 196413 CLEV-MAR. L. R. (3)BurnsAmong the most frequently burned areas of the body arethe hands. Children frequently grasp hot objects. Small, deepburns of the hand are more serious than similar injuries of otherparts of the body. Careful diagnosis of the burned hand is mostimportant. The differentiation between partial 5 and full-thick-ness 26 skin loss is essential for proper therapy, early healing,and ultimate function.Partial thickness burns will heal spontaneously if the physi-cian will protect the remaining viable skin. Many methods ofmanagement and a great variety of materials have been advo-cated. Under controlled conditions, considerable latitude is al-lowed. Partial thickness burns of the hand should be managedby the closed technique. This includes immobilization in an oc-clusive dressing with the individual fingers separated and thehand in the position of function. Loose epithelium and the topsof vesicles should be debrided and the hand cleansed with dilutebland soap and water followed with saline. A dressing should beapplied carefully, utilizing fine mesh, nearly dry, grease gauzeto prevent adherence and destruction of young epithelium. Thisis followed by a bulky pressure dressing separating the fingers.Barring complications, second-degree burns of the hand willheal spontaneously in 10 to 14 days. A carefully applied initialdressing need not be changed for five to seven days after injury.At the time of the first dressing change, extreme care should betaken not to injure the newly formed epithelial covering. Whenepithelization is complete, mobilization is begun to prevent fi-brosis 27 and contracture.28 However, the epithelial surface mustbe protected from excessive wear and tear until the covering ismature; this may require two to three weeks.When full-thickness burn occurs, the area involved must besmall if the injury is to be treated on an outpatient basis. Small,deep burns of the hand are managed conservatively until thearea of loss is sharply demarcated and necrotic skin has25 Second degree burn.26 Third degree burn.27 A condition marked by increase of interstitial fibrous tissue.28 A permanent shortening (as of muscle, tendon, or scar tissue) producingdeformity or distortion.Sept., 19648https://engagedscholarship.csuohio.edu/clevstlrev/vol13/iss3/7INJURIES OF HANDsloughed (Figure 7A). When granulation 29 has occurred, thearea must be resurfaced with split-thickness skin grafts as soonas possible, not only to restore skin coverage, but also to preventfibrosis and loss of function (Figure 7B).Figure 7A. A third-degree burn Figure 7B. Eight weeks afterof the index finger in a 30-year- early split-thickness skin graftingold worker, to r e s u rf a c e the granulatingwound and prevent fibrosis.29 One of the minute red granules of new capillaries formed on the surfaceof a wound in healing.9Published by EngagedScholarship@CSU, 1964

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Outpatient Injuries of the Hand

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