Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXXII: Wounds and Injuries of the Hand

Initial Wound Surgery

United States Department of Defense

Anesthesia

Both general anesthesia and conduction (nerve) blocks are satisfactory for surgical management of the wounds of the hand. Local anesthesia does not provide satisfactory anesthesia. Adrenalin is not injected into hands or fingers, since any additional perfusion compromise, coupled with already marginal perfusion, can result in irreversible ischemic changes.

Debridement

Ideally, the surgeon works with an assistant, a good light, and adequate time The surgeon-should operate while seated, with the draped extremity extended and the hand resting on a suitable support. Necessary instruments include fine tissue forceps, skin hooks, straight and curved ophthalmic scissors, small knife blades, and fine needles. Some sort of magnification is essential.

Cleansing of the surgical field prior to operation is of paramount importance. Since the combatant's hand is usually filthy, attention to detail at the time of the initial cleansing under anesthesia is invaluable in diminishing subsequent sepsis. The preparation extends from the distal edge of the tourniquet to the tips of the trimmed fingernails.

Hemostasis must be complete. It is accomplished with the aid of intermittent application of the tourniquet. The tourniquet should never be kept inflated for longer than two hours. It should be released prior to application of the dressing to allow identification and control of bleeding points. Injuries of the radial or the ulnar artery can usually be safely ligated, since both have rich terminal anastomoses. Both arteries should not be ligated.

Trimming of the wound edges should not be routinely carried out. The removal of even a few millimeters of normal skin may necessitate later skin grafting. Contused skin and dirt-tattooed skin is preserved for delayed closure. Only devitalized skin is excised.

The deep structures of the hand should be explored thoroughly to determine the full extent of the injury and to allow adequate debridement. Care must be exercised during wound exploration and debridement to prevent damage to previously undamaged structures. The carpal tunnel may be opened to locate and protect the median nerve and its branches during debridement. Incision of the transverse carpal ligament, in addition to decompressing the median nerve, will improve tendon function in the severely damaged hand. In certain injuries associated with massive swelling of the hand, decompression of the intrinsic muscles may be indicated. Incision of the intermetacarpal fascia through small dorsal incisions reduces the possibility of developing intrinsic contracture.

Dead muscle, tissue, bloodclot, readily accessible foreign bodies, and other debris are removed. Bone fragments that are not grossly contaminated are preserved. Severely damaged and useless tendons should be excised. Every bit of viable tissue should be preserved. During the procedure, the wound is copiously irrigated with physiologic salt solution.

Only digits which are irretrievably damaged are amputated. Amputation of the thumb is a last resort, and is performed only after repeated evaluation. It is sometimes possible to preserve a skin pedicle from a finger that must be amputated, to provide later coverage for the remainder of the hand. In digital amputations, the tendons should be removed with the bone, but the digital vessels and nerves should be retained. Tendon repair, including tendon grafts, should not be performed by the forward surgeon.

Nerves which are traumatically divided are usually disrupted over a considerable distance and should not be primarily repaired. However, nerves which can be approximated in relatively healthy tissue without any tension should be approximated with one or two sutures of nonabsorbable suture material. This will prevent retraction, thereby facilitating future neurorrhaphy. Digital nerves are an exception and when possible should be repaired primarily, with the expectation of avoiding a painful neuroma.

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Operational Medicine 2001

Health Care in Military Settings

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