Basic
principles of treatment
Certain principles must be followed when treating conditions of the hand
and wrist.
Avoiding
swelling and stiffness
The hand swells following injury, surgery or infection (Fig.
30.1); as
it swells it tends to fall into a position with the wrist flexed, the
metacarpophalangeal joints extended and the interphalangeal joints flexed. This
position becomes permanent as the collateral ligaments shrink and the
oedematous tissues fibrose. The hand then cannot function properly. To avoid
this, one must obey the following three principles.
1.Elevation. The hand must be elevated in a high sling or roller
towel (Fig. 30.2), care being taken that the venous drainage is not occluded by
too much elbow flexion.
2.Splintage. The wrist should be splinted initially in the position
of safety — the ‘Edinburgh’ position described by James (Fig.
30.3).
Dressings must not be too tight.
3.Movement. As many joints as possible of the wrist and hand should
be moved as early as possible. Rehabilitation should be planned so that the
fewest possible joints and tendons are immobilised.
Anaesthesia
Many procedures on the
wrist and hand can be performed using local anaesthesia either proximally (scalene
block, axillary block) or more distally (Bier’s block, wrist block,
digital nerve block or tendon sheath block). In general, if a tourniquet is
used for more than about 20 minutes it becomes uncomfortable and so a proximal
block or general anaesthetic is preferred.
For
a digital nerve block, local anaesthetic is introduced into the palm at the
level of the distal palmar crease; this is preferable to surrounding the base of
the finger with a potentially occlusive ‘ring block’. An alternative is to
instill about 1 ml of 2 per cent lignocaine beneath the flexor tendon sheath.
This takes a little more time to work than a digital nerve block, but lasts for
longer and is equally effective.
Tourniquet
A bloodless field is essential for accurate surgery. A well-padded
tourniquet above the elbow, inflated to 75 mmHg pressure over the
systolic blood pressure, is usually satisfactory. The time should not exceed 2
hours. An Esmarch bandage or a rubber-tube exsanguinator are effective, but
should be avoided for tumour or infection cases lest the pathology is spread
systemically. In the finger, a tourniquet can be made by placing a sterile glove
on the patient, snipping off the tip and then rolling the glove down to the base
of the finger.
Incisions
Incisions which cross a flexion crease may produce an uncomfortable
and restrictive contracture. Therefore, surgical incisions should be planned to
cut across flexor creases at 450 or to lie in neutral areas, such as the
midlateral line of the finger. An alternative is to close a straight incision
across a flexor crease with a Z-plasty (Fig. 30.4).
Splints
Splints can broadly be described as resting, static or dynamic
(Fig. 30.5). Resting splints are used to immobilise the hand when
there is active inflammation, for example after injury, after surgery or during
a flare-up of rheumatoid arthritis or infection. Static splints can be used continuously
(e.g. for a fracture until healed), serially (e.g. gradually changing
the angle of a splint to overcome a joint contracture) or periodically (e.g.
a wrist extension splint at night to reduce symptoms of carpal tunnel
syndrome). Dynamic splints allow movement of one group of tendons but not the
antagonist, for example to protect either the flexor tendons or extensor tendons
after repair.