|Year : 2013 | Volume
| Issue : 4 | Page : 229-234
A study of hand injury and emergency management in a developing country
Soumya Ghosh1, Ritesh Kumar Sinha1, Soma Datta2, Arunima Chaudhuri3, Chinmoy Dey4, Abhinay Singh1
1 Department of Orthopaedics, Burdwan Medical College and Hospital, Burdwan, India
2 Department of Pathology, Burdwan Medical College and Hospital, Burdwan, India
3 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, India
4 Department of Orthopaedics, Nil Ratan Sarkar Medical College and Hospital, Kolkata, West Bengal, India
|Date of Web Publication||2-Jan-2014|
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Injury to the underlying structures of the hand carries the potential for serious handicap. To reduce this risk, even the smallest hand injuries require proper medical care.
Aims: To assess wound healing, mobility, and the ability to perform normal essential function post-operatively in open hand injuries associated with fracture.
Materials and Methods: Thirty patients with 45 metacarpal and phalangeal fractures of the hand were divided into three groups: Group 1 (n = 13) cases with single fractures of hand, excluding thumb; Group 2 (n = 9) cases with multiple fracture of hand, excluding thumb; Group 3 (n = 8) cases with fractures involving thumb and first metacarpal. Tendon injuries were repaired. For fractures, Kirschner wire fixation was done. In two cases with multiple fractures, Joshi's external support system (JESS) fixator was applied. Patients were followed up for 12 weeks.
Results: One patient with proximal phalangeal fracture developed extension lag. No stiffness was observed in any of the cases treated by intramedullary Kirschner wire fixation. No non-union or delayed union was observed following cross-wire fixation with two Kirschner wires. Two case of open fracture developed superficial infection. Two patients with multiple fractures developed angulation at fracture site after the Kirschner wires were removed 4 weeks postoperatively, and two cases of multiple fractures developed hypertrophic non-union.
Conclusions: Delicate handling of tissues, preservation of gliding planes for tendons, prevention of infection, accurate reduction and fixation, and early and appropriate physiotherapy affect prognosis in case of hand injuries.
Keywords: Hand injury, management, prognosis
|How to cite this article:|
Ghosh S, Sinha RK, Datta S, Chaudhuri A, Dey C, Singh A. A study of hand injury and emergency management in a developing country. Int J Crit Illn Inj Sci 2013;3:229-34
|How to cite this URL:|
Ghosh S, Sinha RK, Datta S, Chaudhuri A, Dey C, Singh A. A study of hand injury and emergency management in a developing country. Int J Crit Illn Inj Sci [serial online] 2013 [cited 2023 Mar 30];3:229-34. Available from: https://www.ijciis.org/text.asp?2013/3/4/229/124101
| Introduction|| |
Hands are instruments of performance and protection. Any injury to the underlying structures of the hand carries the potential for serious handicap. To reduce this risk, even the smallest hand injuries require proper medical care. Hand injuries are relatively common and account for 5-10% of emergency department visits. , The most common mechanisms of open hand injury are road traffic accidents, blunt trauma (e.g. crush injury, contusions), and assault. , Mutilating hand injuries may be classified by the scheme of orientation, wound type, and zone of injury according to Tic Tac Toe classification [Table 1] by American Society for Surgery of the Hand (ASSH) as follows: 
|Table 1: Wound type and Zone of injury according to Tic Tac Toe classification|
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Zones of injury are shown in [Table 2].
Open fractures of hand can be classified according to Gustilo Andersons Classification System.  Type I: <1 cm clean wound; Type II: >1 cm laceration with no extensive soft tissue damage, skin flap, or avulsion. Extensive soft tissue damage or flaps, but adequate coverage of bone or high energy trauma regardless of size of the wound (like comminuted or segmental fractures even those of < 1 cm); type IIIa: Extensive soft tissue damage or flaps, but adequate coverage of bone or high energy trauma regardless of the size of the wound (like comminuted or segmental fractures even those of <1 cm). Extensive soft tissue loss with periosteal stripping and bone exposure (usually massively contaminated); type IIIb: Extensive soft tissue loss with periosteal stripping and bone exposure (usually massively contaminated); type IIIc: With arterial injury that requires repair regardless of size of soft tissue wound. 
For an acutely injured hand, restoration of function is the goal of treatment. It is necessary to prevent infection, salvage injured parts, and promote primary healing. Bony architecture as well as joint motion must be re-established soon. It is preferable to close the wound within the first 5 days. ,,,, If the injury and wound conditions permits, tendons and nerves should be repaired at the time of primary or secondary skin closure. Although nerves and tendons may be repaired in the primary phase of care, their management is secondary in importance to thorough cleansing and debridement, correct stabilization of fractures and dislocations, and wound closure or coverage with skin grafts or skin flaps. , Primary skin closure is desirable and usually can be done in all sharply incised, clean wounds. The purpose of primary skin closure is to obtain early healing and to prevent infection, granulation tissue, oedema, and excessive scar production. ,, Following open fractures, fixation is usually indicated because of fracture instability. Operative management of such hand injuries leads to early stability. Stability is necessary for wound care and promotes healing. Stability and early mobilization also avoids the problem of stiffness. ,
Objectives of the study were to assess wound healing, mobility, and the ability to perform normal essential function post-operatively in open hand injury with associated fracture.
| Materials and Methods|| |
This prospective observational study was carried out in a tertiary care hospital in West Bengal in a time span of 1 year on 30 cases with open hand injuries and associated fractures. Approval of ethical committee and consent of the patient was taken before conduction of the study.
Patients >18 years of age with open hand injury and associated fractures were selected for the study.
Patient with mental instability, co-morbidity of hand like associated amputation of digits or open fractures with severe soft tissue injury (Gustilo type IIIc), old stiffness or deformity before sustaining injury, and having other bony injury in the same limb were excluded from the study.
Forty-five metacarpal and phalangeal fractures of the hand in 30 patients were included. After proper history taking, clinical examination and investigations patients were sent to the operation theatre. The injured hands were held over a drain basin and scrubbed with antiseptic soap and water to above the elbow, under general or regional anaesthesia. The nails and nail beds were cleansed, and the nails were trimmed. The wound was exposed and irrigated with normal saline to remove any foreign particles and hematomas. After a diligent effort had been made to convert the contaminated wound into a clean one in the operating room, the wound was re-examined. Initial debridement was done in the cases of infected and contaminated wounds. After cleaning the wound, the bony architecture was re-established immediately.
The cases were divided into three groups: Group 1 (n = 13) cases with single fractures of hand, excluding thumb, Group 2 (n = 9) cases with multiple fracture of hand, excluding thumb, and Group 3 (n = 8) cases with fractures involving thumb and first metacarpal.
In two cases, only soft tissue coverage was done around fractures because of their minimal displacement and stability (an unstable fracture was defined as the one in which the patient was able to move the adjacent joints by less than 30% of the expected normal range of motion).  Tendon injuries were repaired. For fractures, Kirschner wire fixation of the fractures was done because of easy availability of Kirschner wire in an emergency set up. In two cases with multiple fractures, Joshi's external support system (JESS) fixator was applied. Secondary debridement was done after 24-48 hours in seven cases, and secondary skin closure was done in five cases. In two cases where there was mild skin loss, wound was left to heal by secondary intention.
After initial treatment, the hands were kept elevated and the patients were encouraged to perform movements of the fingers and hand to prevent edema and stiffness.  Antibiotics were given for 48 hours and prolonged in cases of contaminated wounds. The Kirschner wires and external fixation devices were removed between 3 and 6 weeks. Active assisted mobilization was started after removal of Kirschner wire/external fixator, usually at 3-6 weeks. Wax bath were given. Patients were followed weekly for the first month and fortnightly for the next 2 months before the final evaluation at 12 week. It was based on total active range of motion for digital functional assessment as suggested by the American Society for surgery of hand, ,, and self-report questionnaires, Quick Disabilities arm shoulder and hand (QuickDASH). 
Analysis of outcome measures
Opposition of the thumb causes the pad of the thumb to face (oppose) the pads of the fingers. Opposition cannot be measured with a goniometer. The American Academy of Orthopaedic Surgeons suggests that opposition range is normal when the tip of the thumb can touch the base of the fifth finger. When range is not adequate, a ruler can be used to measure the distance between the tip of the thumb and the base of the fifth finger. The total ROM achieved when all three joints-metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) of a digit are actively flexed or extended simultaneously, minus any extension deficit at any of the three joints [Figure 1]. In order to test the opposition and the counter-opposition (reposition) of the thumb, the method proposed does not require the measuring of angles; instead, the hand itself is used as the system of reference. The opposition test consists of touching the four long fingers with the tip of the thumb; the score is 1 for the lateral side of the second phalanx of the index finger, 2 for the lateral side of the third phalanx, 3 for the tip of the index finger, 4 for the tip of the middle finger, 5 for the ring finger, and 6 for the little finger. Then, moving the thumb proximally along the volar aspect of the little finger, the score is 7 when it touches the DIP crease, 8 on the PIP crease, 9 on the proximal crease of the little finger, and 10 when it reaches the distal volar crease of the hand. This test is valid only if the first stages are possible: A crawling thumb in the palm is not an opposition motion. The counter-opposition test (or reposition test) needs the other hand as a reference system. The hand to be tested is set upon the table palm-down, while the other hand is laid on the table on its medial side, close to the tip of the first hand thumb; now this thumb is actively drawn up as high as possible. ,, The QuickDASH using 11 items to measure physical function and symptoms in patients with any or multiple musculoskeletal disorders of the upper limb was used to assess QuickDASH. Final evaluation of functional outcome was done at the end of 3 months. It was based on total active range of motion for digital functional assessment as suggested by the American Society for surgery of hand,  and a self-report questionnaires, QuickDASH.  The final score can be calculated using a simple formula: DASH score = [(sum of n response) - 1] ×25, where n = number of completed response. The questionnaire took a patient 10-15 min to complete. Scaling was ranked from 0 indicating least disability to 100 indicating most disability [Figure 1].
|Figure 1: (a) MP flexion/extension, (b) PIP flexion/extension, (c) DIP flexion/ extension|
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| Results|| |
A total of 30 patients of open hand injury with associated fractures were studied and analyzed. The mean age of the patients was 31.13 years (range 18-45 years). Patients <25 years constituted 50% of the total cases (n = 15). Males (n = 21, 80%) were affected more than female (n = 9, 30%). Male: Female ratio was 2.3:1. The commonest mode of trauma was roadside accidents (76%). Average delay in presentation was 5 hours. Overall, 43 digits were involved and there were a total of 45 fractures. Twenty-three patients had only a single digit involvement, while two digits were involved in four patients and three digits in three patients. Metacarpal fractures (n = 19) comprised 42.1% of the total fractures. Proximal phalanx fracture (n = 11) and distal phalanx fracture (n = 11) were the second most common fracture with 24.4% each. Middle phalanx fracture (n = 4) was least common with 8.9%. Ten hands had more than one fracture and multiple metacarpal fractures were the most common combination. Articular involvement was observed in three fractures.
Fracture site and configuration are shown in [Table 3].
Average healing time was 13.3 days (range 12-21 days). The final functional outcome after the fracture treatment was assessed at 12 weeks by calculating total active range of motion by total active motion (TAM) scores of the American Society for Surgery of the Hand. This was done by adding the active flexion at MCP, PIP, and DIP joints, after subtracting the sum of extension deficit at these three joints. Recovery is calculated as percent-regained motion compared to normal range of digital motion (260° for fingers, 160° for thumb). According to this, patients with 100% of movement are classified as excellent, 75-99% as good, 50-74% as fair, and <50% as poor.
Group 1 (n = 13) in which only single fracture was present, TAM score was excellent (n = 1, 7.7%) and good (n = 9, 69.1%) in 76.8% cases, whereas fair (n = 2, 15.3%) and poor (n = 1,7.7%) in 23% cases. The average QuickDASH score was 14.16.
Group 2 (n = 9) in which multiple fracture was present, had good (n = 3) TAM in 33.3% cases, whereas fair (n = 4, 44.4%) and poor (n = 2, 22.2%) in 66.6% of cases. The average QuickDASH score was 32.58.
Group 3 (n = 8) comprising of thumb and first metacarpal injury had excellent (n = 1, 12.5%) and good (n = 3, 37.5%) TAM in 50% cases, whereas fair (n = 2, 25%) and poor (n = 2, 25%) in 50% cases. However, opposition of thumb was very good with average Kapandji's score of 8.25 (82.5%). The average QuickDASH score was 26.99.
The overall end results of open hand fractures in 30 patients managed by surgical stabilization were excellent in two (6.67%), good in 15 (50%), fair in eight (26.67%), and poor in five (16.67%). Overall, average QuickDASH score was 24.3.
Best results were obtained in cases with single open fracture. Multiple open fractures were associated with poor result in maximum cases.
A total of 22 complications were observed in 10 patients out of a total of 30 as shown in [Table 4].
| Discussion|| |
Hand injuries are high-energy complex conditions that are challenging to manage. They require careful planning and meticulous execution of treatment.  A low incidence of excellent or good TAM (56.7% good result) was observed in open fractures. Pun et al., reported a lower grade of TAM in open fractures (42% good result) as compared to closed fractures with 70% good results.  Page and Stern reported excellent TAM in 67% of closed fractures with only 24% in open fractures.  Tan et al., observed that open fractures had poor final TAM as compared to closed fractures, although all cases were intraarticular in their series. 
External fixator was used for surgical stabilization of two open fractures. Advantage of external fixation is that no joint transfixation is required and hence patients do not develop any stiffness of the adjacent joints. Fifty percent (n = 1) of the fractures treated by this technique achieved good TAM. The results are comparable to those reported by Freeland et al., (70% excellent to good TAM).  However, the results of the present study were inferior to those obtained by Schuind et al., who reported 96% excellent to good TAM.  This is probably on account of the fact that their study included only closed fractures, whereas external fixation was used for only open fractures with multiple affection in the present study and final outcome is definitely expected to be compromised to some extent in open injuries.
Capo et al., in 2011 retrospectively reviewed patients with open hand fractures and/or dislocations managed between 2001 and 2009 in a hospital in New Jersey. The management protocol consisted of irrigation and debridement, reduction (if necessary), splinting, and antibiotics administration in the emergency department, and patients with vascular compromise or severe mangling open wounds were operated. Overall, 145 cases were included in the study (91 class III, 41 class II, and 13 class I: Injuries according to modified Gustilo-Anderson classification,). In 102 cases, management took place in the emergency department. In the other 43 cases, additional management took place in the operating room. Antibiotics were administered within 4 hours after injury, and irrigation and debridement were performed within 6 hours. Each of the two infections (1.4%) developed in a class III injury. They suggested that in, particularly, type I and type II wounds, the protocol followed can be appropriate when the injury is not of severe mangling type and does not require acute vascular repair. 
Reduction with Kirschner wire fixation was done for stabilization of 35 fractures using three different techniques. Retrograde insertion of Kirschner wire (n = 25) with transfixation of joint was first advocated by Vomsaal.  No significant stiffness was observed in cases of metacarpal fractures treated by this technique when MCP joints were fixed in flexion, while one proximal phalangeal fracture developed extension lag when PIP joint was fixed in flexion. Intramedullary, Kirschner wire without transfixing the joint (n = 6) is technically more difficult than retrograde Kirschner wire fixation. No stiffness was observed in any of the cases treated by this method. Cross Kirschner wire fixation using two Kirschner wires was done for stabilization of four fractures. The advantage of this technique is that it does not permit rotation of fracture fragments, thus making early mobilization possible, as compared to the technique of intramedullary fixation where chances of rotation of fragments do exist. However, Ikuta et al.,  reportedly observed distraction with crossed Kirschner wire fixation using two wires, thereby holding it responsible for delayed union and non-union. However, no non-union or delayed union was observed by us following cross-wire fixation with two Kirschner wires. It is desirable that, while using cross Kirschner wire fixation, crossing point of the wires should not be located at the fracture site so as to avoid distraction.
Finger stiffness was the most commonly observed complication in the present series. Two case of open fracture developed superficial infection. None of the cases developed osteomyelitis. Two patients with multiple fractures developed angulation at the fracture site as the Kirschner wire was removed 4 weeks postoperatively before any radiological union. Two cases of multiple fractures developed hypertrophic non-union after Kirschner wire fixation. The cause was thought to be inadequacy of Kirschner wire fixation, which cannot check movements at fracture site completely. Ikuta et al.,  have also blamed improper Kirschner wire fixation for non-union.
| Conclusions|| |
Many factors, such as delicate handling of tissues, preservation of gliding planes for tendons, prevention of infection, and early and appropriate physiotherapy in addition to accurate reduction and fixation affect prognosis in case of hand injuries .
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[Table 1], [Table 2], [Table 3], [Table 4]
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