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Acute Hand Injuries
Under most circumstances direct primary repair (suture) of sharp lacerations to skin, tendons, muscles, larger blood vessels and bones achieves excellent recovery of function when there is no tissue loss. The main exception with respect to tendons is flexor tendons within the fibrous flexor sheaths of the fingers where smooth gliding of tendons through flexor sheath pulleys is difficult to restore. Bone which has been divided by a saw, like any other simple fracture, usually unites well after appropriate treatment leading to excellent recovery of function.
There may be more tissue damage than is caused by sharp lacerations but avulsed tendons and ligaments can often be repaired with excellent results and dislocated fingers often heal well with minimal treatment.
Crushed skin, tendons, muscles, blood vessels and nerves recover less well than after sharp injuries and many lacerations are partly sharp and partly cutting. Crushing is an important cause of tissue loss.
Infection may complicate or even constitute a valid third party claim. Permanent impairment often results from scarring.
Tissue loss may result from sharp removal or avulsion of tissues and structures or, more seriously, from crushing damage to blood vessels leading to necrosis, from burning (heat, chemical or freezing) and also from infection and combinations of all of the above. Ionising radiation causes slowly progressive tissue damage, scarring and necrosis.
Hand therapists provide specialised physiotherapy for hand conditions which, importantly, includes making or providing splints and devices which assist recovery of hand function. Hand surgery is directed mainly at improving the function of the hand, specific exercises to re-establish joint and tendon movement is an integral part of any operation which can lead to stiffness of the hand. Following some procedures, precise splinting and exercises within strict limits are important. The assistance of a hand therapist is then essential but, following simpler procedures, some people are able to take responsibility for their own hand therapy if the surgeon explains what they must do and follows up their progress. Mr Buntine is particuarly interested in rehabilitation of the hand after operation or injury.
The AMA 4 Guides direct impairment assessment to measurable trauma caused abnormalities such as ranges of joint movement, level of amputation of a finger or thumb, two point discrimination (for assessment of sensation of fingers and thumb) and observation of the effects of pain.
Chronic Hand Injuries and Conditions
This is stenosing tenosynovitis affecting the extensor tendons of the lateral (radial) side of the wrist. The pathology is the same as that which causes trigger finger and thumb except that different tendons are affected. For treatment see trigger finger and thumb.
Triggering results from tightness (stenosing tenosynovitis) affecting the pulley at the base of a finger or thumb through which the flexor tendon glides, causing the finger or thumb to trigger. A steroid (cortisone like) injection usually relieves the condition for a time. Surgical decompression cures trigger finger and thumb (and also de Quervain's tendinitis). Manual activities, including activities at work, initiate or aggravate trigger finger and thumb and de Quervain's tendinitis. When a person is performing work known to cause these types of tendinitis, early acceptance of liability for treatment is common and treatment usually achieves a good outcome.
The inherited tendency to develop Dupuytren’s contracture is dependent upon a northern European ancestry. The little and/or ring fingers are usually affected first by thickening and then tightening of the fine tendon like strands of palmar fascia of the palm and fingers. Working does not cause or significantly aggravate Dupuytren's contracture although it seems a local injury may occasionally do so. However the usual long delay between an incident and the development of a contracture makes, for practical purposes, a claim for the condition impossible.
Ganglia are common fluid filled sacs which arise from joints and fibrous tendon sheaths. They contain lubricating fluid (synovial fluid) and often fluctuate in size. Surgical treatment is often appropriate and the results of treatment are usually good. However, some ganglia in particular are prone to recur. There is minimal evidence of causation of most ganglia by trauma.
Acceptance of liability for the occurrence of and for the treatment of scars of the hand and wrist following work injury is ordinarily straight forward. Surgery for tight narrow scars may involve division of the tight band of scar followed by rearrangement of the skin (flap repair, particularly z-plasty) or, for broader scars, a skin graft or both flaps and grafts. Impairment assessment depends upon limitation of movement and/or the other criteria set out in the AMA Guides.
Re-growth of troublesome nail remnants is very common following fingertip amputations. Considerable attention to detail is necessary to avoid this annoying complication by completely removing all remnants of damaged nail bed. The apparently minor surgery necessary to remove nail remnants depends upon good facilities, a finger tourniquet, skill, experience and close attention to detail.
All statements on the www.johnbuntine.com website are intended for educational and informational purposes. The information is not intended nor suited to be a replacement or substitute for professional medical treatment or for professional medical advice relative to a specific medical question or condition.
