Hands are in the most frequent contact with the outside world, which makes them vulnerable. In orthopedic emergency patients, hand injuries account for about a quarter of the total number of patients, while open hand injuries account for two-thirds of the total number of hand injuries. The prevention and treatment of hand trauma is an important subject in the field of surgery. In particular, we must emphasize the early treatment of complex emergency hand injuries, and we must take a positive attitude towards such injuries. If early treatment is correct, a second operation can often be avoided. If the injury is serious and cannot be repaired early, we should try our best to create conditions for later repair during early surgery.

Initial hand surgery treatment

The initial surgical treatment is the main link in the treatment of hand injury and the basis for further treatment in the future. The principles of management are: early thorough debridement to prevent wound infection; Try to repair the damaged tissue and maximize the function of the hand. The specific steps are ① debridement, ② tissue repair, ③ wound closure and ④ bandaging and fixation. Hemostasis should be stopped in time and tetanus antitoxin and anti-infective drugs should be injected.

(a) anesthesia surgery should be carried out under perfect anesthesia. Single finger injury can be anesthetized by finger nerve block; Wounds involving palm, back of hand or multiple fingers can be used as wrist nerve block; Larger wounds are best performed under brachial plexus anesthesia.

(2) The purpose of debridement is to remove dirt and foreign bodies from the wound, remove the tissue that has lost vitality, and turn the contaminated wound into a clean wound (not a sterile wound) to prevent infection. The specific method is the same as the general trauma chapter. But stressed:

1. This is an important step to prevent wound infection and should be done seriously, although the method is simple.

2. The principle of debridement should be followed, and debridement should be carried out in a planned way from outside to inside. The structure of the hand is complex, fine and rich in circulation. During debridement, the tissue with blood supply should be preserved as much as possible and the skin margin should be cut less.

3. At the same time of planned debridement, comprehensively and systematically examine the injured tissue, estimate the degree and scope of injury, and loosen the tourniquet to observe the circulation of tissue (such as muscle and skin) when necessary, so as to make a comprehensive surgical plan.

(3) Handle the hand trauma of the injured tissue at ordinary times, and repair the injured tissue as soon as conditions permit. Because the anatomical relationship is clear at this time and the secondary degeneration is slight, it is not only easy to operate, but also has good effect and rapid functional recovery. The processing sequence is:

1. Treatment of bones and joints. As the general principle of debridement, try to keep bone fragments and only take out completely free small bone fragments. After reduction, cross fixation with kirschner wires (Figure 1). Compression screws can also be used for long oblique fractures. Intramedullary fixation through adjacent joints was not performed. Suture the opened joint capsule.

2. Repair tendons and nerves.

3. The injury of the first finger artery or the common finger artery has little effect on the blood circulation of the finger, so it can not be repaired. Bilateral digital arteries are completely cut off, which often causes insufficient blood supply to the fingers and needs to be repaired.

(4) Sealing the wound is an important measure to prevent wound infection. Only by closing the wound on the basis of thorough debridement can we protect the exposed deep tissue, prevent bacterial invasion and prevent infection. Rich hand circulation and strong anti-infection ability. Generally, the time limit of hand wound closure can be extended to 12 hours after injury, but it is not fixed and can be increased or decreased according to the nature of injury, pollution degree and temperature. There are several ways to sew a wound:

1. The skin can be sutured directly without or with few defects, but forced tension suture is prohibited. For straight wounds that cross joints, perpendicular to palmprint and parallel to webbed fingers, local Z-shaped skin flap transfer should be done to avoid scar contracture.

2. Free skin grafting can be carried out because there is still a tissue bed with good blood supply at the wound base of skin defect, and the bones and tendons are not exposed. The exposed small bones and tendons can be covered with nearby soft tissues (muscles and fascia) or soft tissue flaps, and then skin grafting is carried out. Generally, medium-thick skin graft is better, and full-thickness skin graft can also be used for finger pulp and palm.

3. Skin flap covers bones and tendons and is exposed, so skin flap is often needed.

(1) The fingertip defect of local flap can be covered by various fingertip flaps and thenar flaps. The back of hand can be covered with local arbitrary flap, and thumb and tiger's mouth can be covered with dorsal index finger flap or island flap with neurovascular pedicle.

A. digital triangle flap b.V-Y flap C. digital dorsal rotation flap D. digital dorsal double pedicle push flap

(2) The adjacent finger flap is a flap formed by the dorsal skin of the adjacent finger, which is often used to cover the fingertip or pulp defect.

① Free skin grafting ② After the dorsal digital flap was transferred to the palm of the finger.

(3) Large-area exposure requires large-area distal flaps, such as arm cross flap, abdominal flap, iliopsoas muscle flap, etc. Due to the rapid development of microsurgery technology, various free flaps have been designed in recent ten years, providing more choices for hand trauma. Forearm flap, saphenous artery flap, medial and lateral upper arm flap, groin flap and dorsum pedis flap are more suitable for hands and can be selected according to specific conditions.