HAND injuries need expert care
Why should Hand injuries be treated by a Plastic surgeon
1. How can somebody get a hand fracture?
There are several reasons for a hand fracture. commonest reason is fall on ground and landing on hand or fingers. In addition fractures do occur with motor vehicle accidents, crush injury due to various mechanical appliances in industrial and domestic use. Often these hand fractures are taken easy or not attended. Traditionally there is a temptation to seek indigenous medical advice.
2. What are the problems a patient is going to face with a hand fracture?
Hand fracture is not deadly and not going progress to a cancer or deadly disease. However, it will affect the function of the hand. If the injury is in the dominant hand the loss of function may affect the patient’s life significantly.
The loss of hand function is due to two reasons. One is the fracture causing deformity. Other reason is the inappropriate treatment leading to stiffness and loss of function. Therefore one has to be aware that hand fracture can become miserable if not treated properly.
3. How urgent to attend fractures in the hand?
The fractures in the hand could be open or closed. Open fracture means there is a wound associated with the fracture and there is very high chance of bone infection. So those cases are very urgent to be attended and need to be taken to an operating theater for a wound wash out. Once the wound is attended the fixation of the fracture may not be very urgent. It should be done properly and only once ideally. Repeated surgery or manipulations would lead to wound problems and poor healing of the fracture.
Closed fractures or fractures without a wound associated would be alright to be attended in couple of days. But should not be delayed for weeks.
4. Do all fractures in the hand need surgical intervention?
Not at all. Some of the un-displaced fractures can be managed without surgical intervention and only with splinting. When the fractures are displaced and angulated they should be attended surgically and fixed to prevent deformity and non healing of fractures.
The surgical fixation of the hand fractures could be again done without making surgical incisions or without opening the fracture site under x ray guidance during surgery. The other option is to open the fracture and then go for a fixation of the fracture.
The fixation of the fracture can be done with wires, screws and plates.
5. What is the best way of managing a fracture?
The management plan of the fracture would depend on the extent of the damage. The fractures are going to heal spontaneously and in western medicine we do not prescribe any magic drug or local application which would expedite the fracture healing.
The surgical intervention is to keep the fracture ends aligned and support the natural process of healing. Most of the fractures are going to heal if they are immobilized for an adequate period of time. However, if the immobilization is too long, hand may become totally stiff and may not function although the fracture is perfectly healed. Therefore the management should balance the bone healing and stiffening of the hand joints.
If the fracture can be rigidly fixed with screws and plates, the hand can be mobilized from the following day after surgery. Then the chance of hand becoming stiff is less. However, this way of managing fractures is costly and may not be available in many hospitals.
If the fracture is fixed semi rigidly with wires only the mobilization would be restricted for sometime and chances of hand getting stiff is high.
6. Are you telling that using screws and plates for hand fractures is better always?
I can not say like that and infact, there are fractures which cannot be fixed with screws and plates and also the use of screws and plates may cause wound complications. Main problem with plating is the tendons getting adhered to the plate and restricting the mobilization. When the fixation occurs with screws only the problems are less. But we cannot do that for all fractures. However, use of plates and screws give better results although it is costly.
7. How long does fractured hand take to heal ?
Usually the hand fractures are considered to be adequately healed for mobilization after 6 weeks. Anyway this does not mean that the hand can be used for heavy manual work after six weeks. One should not use the hand for heavy manual work for 10 to 12 weeks. It is always better get the advice from a hand surgeon before proceeding to normal work and if not repeated fracture would give miserable outcome to the patient.
8. What would you do if a fracture does not heal properly?
The improper healing could be non healing, healing with deformity. The fracture non union has to be explored and fixed with screws and plates with bone grafting.
The deformed bone can be shaped up again with various surgical techniques and fixation with screws and plates. These surgical procedure are technically demanding and could be done by a properly trained hand surgeon.
9. How can the fractured hand be protected till it heals?
Traditionally, the hand fractures were immobilized with a protective plaster of paris splint. The problem of this plaster of paris splint is that it can not be removed for washing the hand and it becomes very smelly after sometime. Therefore we use a plastic splint which can be removed and put back securely without jeopardizing the fracture. These splint should be made for the shape and purpose under the instruction of a hand surgeon. In teaching hospital of Kandy we have trained therapists to do this kind of world class work.
10. What is the role of plastic surgeons in hand fracture management ?
Traditionally, all the fractures were managed by indigenous physicians and no surgical intervention described in the Ayurvedic medicine. However, the common belief is that all most all these can be managed by Ayurvedic physicians. It is an unfortunate situation where most of the hand fractures are mismanaged and end up in deformity.
Then the other belief is orthopaedic surgeons could manage all the fractures. Obviously skull fractures are fixed by neurosurgeons and facial fractures are fixed by oral surgeons and plastic surgeons. Like wise in the developed world the hand fractures are managed by the plastic surgeons who have a special training in hand fracture management. In addition the hand fracture could be associated with a damage to the other structures of the hand.
Since the injury to structures like tendons or nerves should be ideally handled by a plastic surgeon, it is always better for the patient to get the plastic surgeon to handle a hand fracture.
In addition some of these fractures may be associated with some soft tissue loss and need a reconstructive procedure to cover the defect which could only be performed by a plastic surgeon. If somebody has read the series of articles published on hand surgery it would be more clearly understood.
11. Are these plates and screws used in hand fractures harmful to the body or should they be removed after sometime?
This is again a misnomer. Leaving a plate and screws is not going to cause any harmful effect. Anyway if someone is too much worried we offer removal after six months of surgery. However if the plate is causing problems like pain and tendon adhesions, it may be removed earlier than 6 months. When we use screws only for fixation, they do not cause any issue and can be left alone