Case Study Newsletter
Winter 2016
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Welcome to the HANDOC Case Study Newsletter where we present some recent hand and wrist injuries, together with some useful diagnostic and treatment insights for our referrers. 1300HANDOC offers a comprehensive 24/7 streamlined service for acute management of workplace hand and wrist injuries in Western Australia.
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HANDOC is operated by WA’s largest group of specialist hand surgeons. Call 1300HANDOC for immediate triage or advice.
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CASE STUDY 1
Container Crush
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Summary
A sea container fell on Mr W’s non-dominant left hand causing significant soft tissue injury to the dorsum, in addition to open fractures of the index, middle, ring and little fingers. Mr W was first taken to a regional hospital ED where he was stabilised, given IV analgesics, antibiotics, tetanus update and then referred to 1300HANDOC. Mr W was then transferred via Royal Flying Doctor Service to St John of God Hospital, Subiaco. The hand was debrided and a k-wire fixation carried out. A second operation was then undertaken to reconstruct the dorsal soft tissue defect using an adipofascial anterior lateral thigh free flap, with split-thickness skin graft for coverage.
Hand therapy commenced first week post-op for splinting and in week 7 all k-wires were removed. At 4 months post surgery Mr W could form a fist close to 75% of normal range, but for such a traumatic injury, full functional recovery is not expected. To reach maximum medical improvement more than 12 months of ongoing rehabilitation and therapy is required.
Clinical Insight
The size of the defect meant that direct closure was not possible. Further, the significant tissue loss and exposed underlying structures meant that a sufficient wound bed was not available for a full-thickness skin graft. Consequently, tissue with its own blood supply in the form of a free flap was necessary. This type of surgical procedure takes approximately 4-6 hours.
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Pre-Operative X-Ray
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Post-Operative X-Ray
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Post wash out and k-wire / Post free flap
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Post Operative - 5 Months
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CASE STUDY 2
Engine Belt Laceration
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Summary
Mr X’s left little finger was caught in an engine belt, resulting in a dorsal distal phalanx laceration extending into the nail bed. Mr X was taken to his occupational GP where a ring block was applied for pain relief, the wound cleaned, a jelonet dressing applied, tetanus updated and then referred to 1300HANDOC. Examination revealed a complex nail bed laceration and X-rays demonstrated an underlying fracture of the distal phalanx. Under local anaesthetic the nail was removed, fracture washed out and nail bed laceration repaired under magnification using fine dissolving sutures. Dressing was changed at one week and mallet splint applied for protection. Mr X has achieved a good range of movement and nail regrowth is normal.
Clinical Insight
A fracture to the tuft of the distal phalanx does not typically require surgical intervention, but where communication with a laceration has occurred, then an infection mitigating wash out is required. Displaced fractures involving the proximal 2/3 of the distal phalanx, particularly those involving the joint surface, are likely to require surgical reduction/fixation. Untreated or inadequately treated nail bed injuries can lead to chronic nail pain and deformity, including splitting, catching, in-growth and associated loss of function.
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Pre-Operative Injury
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Pre-Operative X-Ray
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Post Operative
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Post-Operative Flexion
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