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Airless gun injection injuries of the hand are a surgical emergency. The injection of paint or paint solvents are the most pernicious, whereas grease or diesel fuel injections have a better prognosis for the victim. Tissue necrosis and subsequent morbidity results from the diffusion of the noxious substance. Solvents and paint generate the most severe inflammatory response. Prompt major surgical treatment can minimize morbidity.
At last, flexor tendon injuries of the hand and digit are no longer nearly impossible to treat. Many recent studies have reported a more than 75% success with excellent results, in particular in zone 2, in some cases reaching 98% satisfactory outcomes. The challenge inherent in treating and rehabilitating the zone 2 flexor tendon injury remains, however, even for the skilled hand surgeon. We must remain diligent, obeying principles outlined earlier by the first surgeons willing to attempt these repairs, while carefully gleaning the helpful and critical recommendations of the now sophisticated researchers in the subject of flexor tendon repair and rehabilitation.
After surgery for trauma or correction of congenital anomaly, hand function is difficult to evaluate in children because there are no reference norms on children 3 to 5 years old. The purpose of this study was to determine whether reproducible normative values for hand dexterity and grip and pinch strength could be obtained in young children using simple tests that could be administered quickly within the attention span of a 3- to 5-year-old. The Functional Dexterity Test (FDT), a pegboard test validated for adults and older children, seemed to meet our requirements for dexterity. The FDT was administered to a convenience sample of normal children in a prekindergarten school who were grouped according to age: 3-year-olds (n = 17), 4-year-olds (n = 24), and 5-year-olds (n = 22). Hand dominance was determined. The task was demonstrated by 1 of the 2 testers. The child was asked to turn the pegs over in the pegboard without using the free hand or balancing the peg against the chest. Both hands were tested. Grip and pinch strengths were measured in both hands in a consistent manner. All the children were tested with the arm at the side and the elbow at 90 degrees. A dynamometer was used for grip strength and a pinch meter was used to measure key (lateral) and tripod pinch strengths. Means and SDs were calculated for each age group, and the dependent values of dexterity, strength, and dominance were correlated. Dexterity and strength scores were significantly different by age group. A good FDT score in the dominant hand was predictive of a good score in the nondominant hand. Grip and pinch strength correlated poorly with functional dexterity. The normative values established in this study for children in the 3- to 5-year-old range can be referenced for disability estimates and establishing goals for children after surgery or hand injury.
Closed tendon injuries in the hand are common in the athlete. Neglect of such injuries may result in irreparable damage to the hand. Even seemingly minor injuries must be carefully evaluated and treated by a physician. Early diagnosis, accurate and precise treatment, and proper rehabilitation are extremely important to regain optimal function after these injuries. Most of the injuries can be controlled by conservative means. However, when surgical repair is indicated, it is important for the surgeon to be trained and familiar with the anatomy and techniques of surgery of the hand.
Controversy exists in the literature concerning the ability of the five-rung grip test to identify submaximal effort. The purpose of this study was to analyze four methods commonly used to evaluate the shape of the curve generated by maximal versus submaximal efforts. Thirty hand therapy patients performed the five-rung grip test maximally and submaximally with both their injured and uninjured hands. Grip strength scores were recorded at each of the five-rung positions. Next, four methods were used to analyze the data 1) visual analysis, 2) analysis of variance, 3) normalization, and 4) calculation of the standard deviation across the five strength scores. Analysis by all methods demonstrated that there were no differences between the injured hand exerting maximal effort and the uninjured hand exerting submaximal effort. In all four methods, the five-rung grip strength test was unable to distinguish between the injured hand exerting maximal effort and the uninjured hand exerting submaximal effort. The results suggest that the five-rung grip strength test should not be used to determine sincerity of effort in people with hand injuries, and that the shape of the curve generated by the five-rung grip strength test may not be related to level of effort but rather to the amount of force generated by the gripping hand.
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Injuries to the hand and wrist are probably among the most common injuries incurred by the athlete. Neglect of such injuries may result in irreparable damage to the hand or wrist. This summary of the more common injuries to these areas seen in the athlete, with a description of the recognition and treatment, gives the reader insight into the multiple considerations the athlete and coach must have. Even seemingly minor injuries must be carefully evaluated and treated by a physician. Early diagnosis, accurate precise treatment, and proper rehabilitation are extremely important to regain optimal function after these injuries. They may have a significant impact not only in athletic competition but also in the athlete's selection of an occupation. It is psychologically important also that the participant be returned to his particular sport as soon as possible. Most of the injuries can be controlled by conservative means. However, when surgical repair is indicated, it is important for the surgeon to be trained and familiar with the anatomy and techniques of surgery of the hand and wrist.
67 tendon sutures were performed on 29 patients using polydioxanon (PDS), a synthetic absorbable suture material. The results after a mean survey period of twelve months are documented; there were no ruptures and fistula, only two infections and in four cases the need for tenolysis. In the reconstruction of isolated flexor tendon injuries 89% excellent results were found. The satisfactory and bad results in reconstructing flexor and extensor tendon injuries accompanied by complex hand injuries are analyzed and discussed.
High-pressure injection injuries of the hand can lead to devastating outcomes. Amputation rates as high as 48% have been reported. The authors review the history of high-pressure injection injuries, with attention to the materials injected, the clinical presentation of these injuries, emergency room and subsequent definitive surgical management of these injuries, the bacteriology and recommendations for antibiotic use in these injuries, and postoperative management.
In the period from 1991-95, 1843 injuries caused by bottles were reported to the Danish EHLASS register, the latter representing 14.2% of the total number of patients seen in the Emergency Room in Denmark. The reports were classified as sharp or blunt injuries; age, sex, and body localisation were registered, and the injuries were grouped into eight body localisations. Hand injuries made up largest group (62%), and of these 92% were sharp injuries. The rest of the injuries (38%) were spread over the other zones, each representing 3-11%. Among the injuries there was a significant overrepresentation of males and young people between 10-24 years of age. Nearly 30% of the injuries were associated with a fall. We estimate that the total number of injuries caused by bottles was 2596/year, and that the incidence rate was 4.98/10,000 person years.
High-pressure injection injuries of the hand represent one of the most serious surgical emergencies of the upper extremity. It is imperative to understand the mechanism of injury and the parts that take place for this injury to occur (material, pressure, site of injury). Prompt recognition and treatment may alter the final outcome.
Electric injuries produce deep tissue destruction and in a large number of cases involve the forearm, entering from the hand. The authors report their experience, consisting of 13 cases, with satisfying results, particularly in relation to limb salvage. Salvage procedures, avoiding the amputation and including venous grafts and use of flaps, among which the inguinal flap is mostly used, are considered. Late necrosis occurring under grafted tissues often requires further surgery, including tendon and nerve grafts and scar revisions with skin grafts or flaps.
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Hand injury patients fairly frequently develop, soon after the injury, hypersensitivity phenomena on contact of the hand with the environment, which may lead to exclusion of the hand. The authors attempt to explain this syndrome on the basis of the pathophysiological theories concerning pain. American authors have proposed an original desensitization treatment based on simple and varied techniques, which provides extremely encouraging results.
The possibilities of hand injuries lead to the higher incidence of hand infections. The clinical signs of inflammation (pain, swelling, heat, loss of function and red colour) are found in near all cases. The start of pain and its localisation help to find quickly the layer of the inflammatory process. Bites, foreign bodies, puncture wounds and open wounds especially those acquired in slaughterhouse or agriculture are in most cases the predisposing conditions. Treatment of hand infections demands a consequent protocol consisting in: exact diagnostics including clinical picture, laboratory investigation, bacteriology and in some cases X-ray-examination; operative treatment including incision, irrigation, drainage, excision of necrosis and foreign bodies under the rules of hand surgery (i.g. blood--[without exsanguination] and painfree operation field, magnifying lenses, correct incision avoiding scar contractures); immobilisation (dressing or splinting) in intrinsic-plus-position while acute inflammation is going on, early movement combined with ergotherapy and physiotherapy after this. Use of antibiotics is indicated in septic cases or in cases of complications (sepsis, lymphangitis, osteomyelitis) in concordance with bacteriology but it cannot compensate mistakes in treatment. The most common infections are placed around and under nail (paronychia) and in the subcutaneous space of the distal phalanx (felon). They are treated by incision and spontaneous drainage. More severe are infections of tendon sheath, joint, web space and deep palmar space. If pus is present in such cases there is no place for conservative treatment but operative treatment under clinical conditions is imperative.
In high-pressure injection injuries to the hand the most commonly injected materials are automotive grease, diesel oil, and paint. We treated twenty-six patients with high-pressure injection injuries of the hand and found that the injection of paint resulted in a poorer prognosis than did the injection of grease. Amputation is often necessary with paint injections into a digit, while injections into the palm have a somewhat better prognosis. The disability time of patients with paint-injection injuries appeared to be directly related to the time elapsed until amputation of the involved digit. Although we were unable to specifically relate the ultimate result to the time elapsed between injury and proper treatment, we continue to recommend early aggressive wide débridement of these injuries.
In major hand injuries, destroyed joints may be treated by joint transfer, arthroplasty or fusion with or without temporary external fixation. Four immediate digital metacarpophalangeal joint Swanson implants in two patients with amputation or devascularizated near-amputation were reviewed with a 14 years follow-up. No infection was noted. Prostheses were stable with a 31 degrees active range of motion and grip strength was 42% of the opposite side. Functional results were "useful" with patients satisfaction. In one patient, heavy manual worker, implants were replaced fourteen years after trauma because of recent pain on one joint and implants fragmentation. The other patient was painless. Immediate Swanson arthroplasty in major hand injuries may be an alternative in metacarpophalangeal joints destruction.
Injuries and diseases of the hand naturally have an enormous impact on hand function and on quality of life, both occupational and social. The majority of hand-injury patients are under 30 years of age. Hand surgery, an established specialty in Sweden since 1969, is of great importance in terms of clinical developments, education and research. In the coming decade, scientific and clinical advances are to be expected in several fields such as nerve injuries including brachial plexus lesion, microsurgery, flexor tendon injuries and tendon transfer. Bioimplant research and new advances at the biotechnological interface will yield new options in nerve reconstruction, microchip implants in the nervous system, and the restoration of muscle-tendon function following injury. Artificial limbs with advanced motor and sensory functions will be important future aids in the rehabilitation of amputees. Transplantation of human hands is another promising reconstructive procedure which may open up new perspectives in the coming millennium.