外科学课件：手外伤（英文版）

HandInjurySurfaceanatomyofthehandTendonsaroundthethumbformananatomicsnuff-box,whichcanbetouchedwhenthethumbisabductedandextended.HandAnatomyExtensorTendons:Coursesoverthedorsalsideoftheforearm,wristandhand.9extensortendonspassundertheextensorretinaculumandseparateinto6compartmentsHandAnatomyExtensorTendons:Theextensortendonsgainentrancetothehandfromtheforearmthroughaseriesofsixcanals,fivefibroosseousandonefibrousThecommunistendonsarejoineddistallyneartheMPjointsbyfibrousinterconnectionscalledjuncturaetendinum.Beneaththeretinaculum,theextensortendonsarecoveredwithasynovialsheath.

HandAnatomyExtensorsdigitorumcommunisareconnectedbyjunctura.Becauseofthis,acompletetendonlacerationproximaltothejunctionmaystillresultinnormalextensorfunction.HandAnatomyFlexorTendons:Coursesoverthevolarsideoftheforearm,wrist,andhand.Unliketheextensortendons,theflexortendonsareenclosedinsynovialsheathsmakingthempronetodeepspaceinfections.HandAnatomyFlexorTendons:Flexorcarpiradialis,flexorcarpiulnaris,andpalmarislongusprimarilyflexthewristHandAnatomyPostureofhandatrestRestpositionHandfunctionalpostureFunctionalpositionHandAnatomy9flexortendonspassthroughthecarpeltunnel:1tendongoestothebaseofthedist.PhalanxofthethumbTheother4digitshave2tendonsrespectively(FDS/FDP).HandAnatomyFlexordigitorumsuperficialis(FDS)insertintomiddlephalanx.Flexordigitorumprofundus(FDP)runsdeeptotheFDSuntiltheleveloftheMPjointwhereFDSbifurcates.FDPinsertsatthebaseofthedistalphalanxandactsprimarilytoflextheDIPjointaswellasallotherjointsflexedbyFDS.(Figure268-5).HandAnatomyBloodsupply(BS):Handanddigitshavedual(BS)contributedbytheradialandulnararteries.HandAnatomyBloodsupply(BS):Proximalportionsofthehand(BS)comefromthedeepandsuperficialarchesonthepalmaranddorsalside.BSofthefingersisdistributedbythedigitalarteriesthatarisesfromthesuperficialpalmerarch.HandAnatomy-Bloodsupply

TheAllen'stest.Thecutaneousnervesupplyinthehand.

M,median;

R,radial;

U,ulnar;PCM,palmarcutaneousbranchofmediannerve;

DCU,dorsalcutaneousbranchofulnarnerve

bellyofdistalphalangeoflittlefingerbellyofdistalphalangeofmiddlefingerFirstdorsalwebspaceBoneAnatomyScapoidLunateTriquetriumPisiformTrapeziodTrapeziumCapitateHamateWristArticulationsRadiocarpalJointProximalportionDistalportionMostsurfacecontactfoundArticulationsMidcarpalJointArticulationbetweenproximalanddistalrowofcarpalsNotanuninteruptedjointDistalRow2degreesoffreedomMovesasafixedunitLigamentSupportVolarCarpalLigamentsVolarRadiocarpalLigamentThreebandsVolarUlnocarpalLigamentScapholunateInterosseousLigamentLunotriquetralLigamentLigamentSupportDorsalCarpalLigamentsDorsalRadiocarpalLigamentDorsalIntercarpalLigamentRadialCollateralLigamentUlnarCollateralLigamentCompositionRoleThetriangularfibrocartilagecomplex(TFCC)isasmallpieceofcartilageandligamentsonthelittle-fingersideofthewrist,locatedjustpasttheendoftheforearmbone(ulna).Cartilageisatoughrubberytissuethatactsasacushionforthejoint.Theligamentsarestrongbandsoftissuethatattachthecartilagetobonesinthewrist.Theligamentsorcartilagecanbetornduringawristinjury.TriangularFibrocartilageComplexTFCCincludesthetriangularfibrocartilage,radioulnarligament,ulnocarpalligament,extensorcarpalulnarissheath,andmeniscushomolog.Itstabilizesthedistalradioulnarjointandfunctionsasacushionofcompressingaxialforces.ItattachesmediallytothefoveaoftheulnaandlaterallytothelunatefossaoftheradiusExtensorIndicisODorsalsurfacelower½bodyofulnaInterosseusmembraneIUlnarsideofindexfinger’sEDCtendonNRadial(posteriorinterosseus)FMCPandIPExtof2nddigitExtensorPollicisLongusOPosterior1/3ulnaInterosseusmembraneIPosteriorsurfaceofbaseofthumbdistalphalanxNRadial(posteriorinterosseus)FCMC,MCPandIPExtof1stdigitExtensorPollicisBrevisODorsal2/3ofradiusIDorsalsurfaceofbaseofproximal1stphalanxNRadial(posteriorinterosseus)FCMC&MCPExtofthumbCMCABDofthumbAbductorPollicisLongusOPosteriordistal2/3ofulnaPosteriormiddle1/3ofradiusInterosseusmembraneIRadialsideofbaseof1stmetacarpalNRadial(posteriorinterosseus)FCMCABD&ExtofthumbFlexorPollicisLongusOAnteriormiddle½ofradiusInterosseusmembraneIPalmarsurfaceofbaseofdistal1stphalanxNMedian(anteriorinterosseus)FIPFlexionofthumbExtensorDigitiMinimiOLateralepicondyleofhumerusIExtensorexpansionof5thdigitNRadial(posteiorinterosseus)FMCPandIPextensionof5thdigitFlexorDigitorumSuperficialisOMedialepicondyleofhumerusCoronoidprocessMiddle½anteriorradiusIFourtendonsseparatingintotwopartsthatinsertintosidesofbasesofmiddle2-5phalanxesNMedianFMCPflexiondigits2-5PIPflexiondigits2-5FlexorDigitorumProfundusOAnteriomedialsurfaceofulnaInterosseusmembraneIFourtendonsinsertingintodistalphalanxesofdigits2-5NMedia2-3digitsUlna4-5digitsFDIPflexionof2-5digitsIntrinsicHandMusclesThenarEminenceAbductorPollicisBrevisOScaphoidtuberosityTrapeziumridgeTransversecarpalligamentILateralbasefproximal1stphalanxNMedianFCMC&MCPABDofthumbFlexorPollicisBrevisOSuperficialhead–trapeziumDeephead–trapezoid,capitateandpalmarligamentsofdistalcarpalbonesIBaseofprximal1stphalanxonradialsideExtensorexpansionNSuperficial–medianDeep–UlnarFCMC&MCPFlexionofthumbOpponensPollicisOTrapeziumTransverseCarpalLigamentIRadialsideof1stmetacarpalshaftNMedianFOppositionIntrinsicHandMusclesHypothenarEminenceAbductorDigitiMinimiOPisiformIUlnarsidebaseof5thproximalphalanxNUlnarFMCPABDof5thdigitOpponenDigitiMinimiOHookofhamateTransversecarpalligamentIUlnarborderofentire5thmetacarpalboneNUlnarFMCPflexion&rotationof5thdigitFlexorDigitiMinimiOHamateboneTransversecarpalligamentIUlnarsideofproximal5thphalanxNUlnarFMCPFlexionof5thdigitOtherIntrinsicHandMusclesAdductorPollicisOObliqueHeadCapitateboneBasesof2-3metacarpalsTransverseHeadProximal2/3ofpalmarsurfaceof3rdmetacarpalIUlnarsideofbaseof1stproximalphalanxNUlnarFCMCADDofthumbPalmarInterosseiO1st–ulnarsidebaseof1stmetacarpalbone2nd–ulnarsideof2ndMCbone3rd–radialsideof4thMCbone4th–radiasideof5thMCboneIExtensorexpansionof2,4and5thdigitsNUlnarFADDof1st,2nd,4thand5thdigitstowardmidlineofhandDorsalInterosseiO1stlateralhead–ulnarsideof1stmetacarpalbone1stmedialhead–radialsideof2ndmetacarpalbone2nd,3rd,4thspacebetweenmetacarpalbonesI1st–radialside2ndproximalphalanx2nd–radialsideof3rd3rd–ilnarsideof3rd4th–ulnarsideof4thNUlnarFABDof2nd,3rd,and5thfingerfrommidlineLumbricalesOTendonsofFDPIExtensorexpansionondorsalaspectofeachdigitsradialsideN1and2–median3and4–ulnarFMCPflexion2-5digitsDIP&PIPext2-5digitsPalmarisBrevisOFlexorretinaculumIPalmarsurfaceskinonulnarsideofhandN UlnarFWrinklesskinofhandonulnarsideTendonAnatomyVerdan’szonesystemTendonAnatomyTodiscusstendoninjury,

amodifiedVerdan’szonesystemwasusedZoneII:distalpalmarcreasetoinsertionofFDSatmidportionofmiddlephalanxNoman`szoneBothflexortendonspassthroughatightfibroosseoustunnelHistory:Shouldincludethetime,thecauseoftheinjuryandevalforthepossibilityofcrush,burn,orchemicalexposure.Thepatient’soccupation,priorhandinjuries,andhandednessshouldbedocumentedPrinciplesofevaluationonOpenHandInjuryThepositionofthehandatthetimeofinjuryshouldbedetermined.Injurieswiththedigitsinflexionmayresultinretractionofthecutendofthetendonwhenthedigitisexaminedinneutralposition.PrinciplesofevaluationonOpenHandInjuryPhysicalExamShoulddetailtheextentofinjurybydocumentingthefollowing:AmountofdevascularizationStatusoftheskinPostureofthefingersPresenceofdeformityActivebleedingB/LgripstrengthPrinciplesofevaluationonOpenHandInjuryPhysicalExamROMandstrengthshouldbetestedagainstresistance.Nervetesting:Testmediannerve:HavetheptflexthedistalphalanxofthethumbagainstresistanceTestoppositionbytouchingthetipofthethumbtothetipofthelittlefingerTheptwillbeunabletoopposeagainstresistenceifmediannervefunctionislost.PrinciplesofevaluationonOpenHandInjuryNervetestingTestmediannerve:Testthumbabductionbyplacingthehandpalmupandraisingthethumbtotheperpendicularwhilepalpatingthebellyoftheabductorpollicismuscletoinsureitiscontracting.PrinciplesofevaluationonOpenHandInjuryNervetesting:TotestulnarnerveSpreadthefingersapartagainstresistanceandthenpushthemtogetheragainstresistance.Testthehypothenarmuscle,extendthefingersandthenmovethefifthfingerawayfromtheothersTestthumbadduction(ulnarnerveinnervatestheadductorpollicismuscles)bringthethumbtightlyagainstthesideoftheindexfinger.PrinciplesofevaluationonOpenHandInjuryNervetesting:TotestulnarnerveAdductorstrengthcanbefurthertestedbyinterposingapieceofpaperbetweenthethumbandthesideoftheindexfingerandthentryingtopullthepaperaway.Totestradialnerve:Extendthefingersandwrist.Withthethumbinthehitchhikingposition,testitsresistancetofurtherextension.PrinciplesofevaluationonOpenHandInjuryNervetesting:SensationDeterminedby2-pointdiscrimination.Normal2-pointdiscriminationis<6mmatthefingertipsandisoften<2mm.Bothinjuredandnon-injuredfingersmustbecompared.Repeat2-pointdiscriminationtesting2–4timesoneachsideofthedigit(80%accuracyisconsideredacceptable)PrinciplesofevaluationonOpenHandInjuryNervetesting:SensationAsensorydeficitimpliesapotentialdigitalarterylacerationbecauseofthecloseproximityofthetwo.Tendontesting:FullROMofeachtendonagainstresistanceshouldbeassessedandcomparedwiththeuninjuredside.PrinciplesofevaluationonOpenHandInjuryTendontesting:Importanttotestresistancebecauseupto90%ofatendoncanbelaceratedwithpreservationofROMwithoutresistance.Painalongthecourseofthetendonduringresistancetestingsuggestsapartiallacerationevenifthestrengthappearsadequate.PrinciplesofevaluationonOpenHandInjuryTendontesting:FDPistestedbyflexingtheDIPagainstresistancewhiletheMPandPIPareheldinextension.FDSistestedbyflexingthePIPagainstresistancewhiletheremainingfingersareheld.PrinciplesofevaluationonOpenHandInjuryFDPistestedTotestforanintactprofundustendon,theexaminermaintainsthedigitinextensionwhilethepatientattemptstoflextheterminalphalanx.PrinciplesofevaluationonOpenHandInjuryFDSistestedExaminationtoassessfunctionofflexordigitorumsuperficialis.PrinciplesofevaluationonOpenHandInjuryAnesthesiaandDirectWoundExamination:SensationandROMshouldbetestedbeforeanesthesiaapplied.Examshouldbedoneunderabloodlessfieldbyapplyinglocaltourniquetorrubbertubearoundthebaseofthefinger.PenrosedrainPrinciplesofevaluationonOpenHandInjuryRadiographs,Consultation,andDisposition:X-ray:shouldincludeaPA,lateral,andobliqueview.Injuriesrequiringimmediateanddelayedfollow-upbyahandsurgeon

Guidelinesforadequateimmobilizationandfollow-upforspecifichandinjuriesPrinciplesofevaluationonOpenHandInjuryTendoninjuries:FlexortendonsMostcommoncauseofflexortendoninjuryisalaceration.Adistaltoproximalfivezone(I–V)classificationsystemforflexortendoninjurieshasbeendevelopedbasedonlocation,treatmentconsiderations,andprognosis.PrinciplesofevaluationonOpenHandInjuryPrinciplesofManagementonOpenHandInjuryControlthebleedinginproperwayanddeclinethecontaminationSearchthedetailsoftheinjuryDebridetheWoundThoroughlyasEarlyasPossibleRepairtheProfoundTissueinCorrectwayClosethewoundwitheffectiveMethodsProperPostoperativeTreatmentLigamentandDislocationinjuriesVolardislocationofDIPjointoflittlefinger.DorsaldislocationattheDIPjtwithoutassociatedfracture

LigamentandDislocationinjuries

LateraldislocationofmiddlefingerPIPjoint.ROMoftheThumbFracturesDistalPhalanx:Fracturesatthebasemaybeassociatedwithflexororextensortendoninvolvement.Thesefracturesaretreatedassofttissueinjurieswithprotectivesplinting.FracturesBennett'sfractureAvulsionfractureofthearticularsurfaceofthefirstmetacarpalwithsubluxationattheCMCjt.WristScaphoidFractureTendonrepairmassivecrushinjury

->debrideandstablizefracturedirtycontaminatedwound

->achievegoodhealingwithoutinfectionlargeskindefectoverflexortendonmechanism