Inspect the Attitude of Hand for;
- Resting position of digits.
- Any deformity, swelling or asymmetry.
Assess the vascular status by examining.
- Color
- Capillary Refill (1-2 seconds)
- Temperature
- Pulses
- Allen’s Test (To verify palmer arches)
Assess Neurological Status
Do motor examination, both active and passive, to see integrity of tendons and nerves (Ulnar, Median & Radial)
Check Sensation by two-point discrimination, light touch, and absence of sweating (in children)
- Assess skeleton by palpating for any tenderness or deformity.
- Assess joints by stressing ligament and noting any instability, crepitus or pain.
- Clinically if there is any suspicion of fracture or dislocation request for plain X-Ray of hand AP & oblique views.
Primary Treatment
Preoperative Care
- Treat pain with injectable analgesia.
- For contaminated wounds start I/V antibiotics covering Staph. aureus like Ampiclox cefuroxine etc.
- Tetanus prophylaxis.
- Light splintage.
- Cover wound with sterile dressing; isolated soft tissue injuries such as ligament, sprain and muscle strain are treated with rest, ice, compression bandage and elevation (RICE THERAPY) with or without immobilization.
Wound Exploration & Debridement
- Under regional block, wound area is cleaned, explored for removal of any foreign material (if present).
- Avoid tourniquet in crush injuries.
- Be conservative in debridement of hand Injuries (Excise only the dead skin).
- Injection injuries e.g. of oil, grease, hydraulic fluid, or paint under pressure are very demanding so immediate decompression is necessary.
- Partial thickness burns are cleaned covered with non-stick dressing.
- Immobilise in Boxers Gloves position.
- ELEVATION of limb
Indications for Replantation/Revascularization:
- Traumatic amputations of:
- Thumb.
- Multiple digits at transmetacarpal level.
- Wrist.
- Forearm.
- At any level in a child.
Controversial Indication
- Replantation of amputation of proximal arm with minimal ischaemia should be decided by attending Plastic Surgery.
- Replantation of amputation of single finger distal to Flexor Digitorum Superficialis should be decided by attending on call
Contra-Indications for Replantation;
- Multiple level of amputation.
- Severe crush injury to the part.
- Degloving injury to the part.
- Prolonged ischaemia time (12 hrs for fingers & 6 hrs for proximal limb amputations).
- Associated life-threatening injuries.
For Replantation, take following measures:
- Take specialized opinion earlier.
- Clean proximal stump.
- Apply compression dressing.
- Avoid tourniquets.
- Wrap amputated parts in moist gauze, place in bag and cool (but not freeze) by placing on ice.
