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Summertime Injuries

With the changing seasons and the welcoming of the summer solstice, variation also occurs in the type of hand injuries presenting to Emergency Rooms. Winter hand trauma associated with snow skiing accidents, frost bite, and snow blowers are now replaced with a myriad of warmer weather upper extremity injuries. In this article, we will examine several types of common summertime hand trauma, as well as some rather unique injuries.

Fingertip Injuries

Lacerations from lawn mowers may be very irregular and contaminated in nature. Fingertip injuries are by far the most common type of injury, as attempts are made to clear clogged grass and other debris from the discharge path of a mower with the engine running. Only time will tell if new safety measures and mower requirements involving "dead-man" switches will be effective. These switches will automatically shut the mower off if the person operating it takes his/her hands from the mower's handles (riding mowers often have this switch built into the seat).

Classification of injury can be time consuming and impertinent. However, Allen's classification of fingertip injury is beneficial in both the diagnosis and in the planning of treatment for these common traumas. M.J. Allen, in his 1980 thesis on conservative management of fingertip injuries, divided wounds into either sharp amputations or crushing injury categories. He then further divided the trauma into four anatomic zones (I,II,III, and IV).

Fingertip injuries are defined as those that occur distal to the tendinous insertion on the distal phalanx in the fingertip. Allen Type I injuries involve only soft tissue loss, and can be managed conservatively, unless the size of the wound exceeds the patient's ability to epithelialize the wound. The extent of skin loss in a fingertip wound in children is usually not a predictor of a final outcome, as these wounds, when left open, will nearly all heal by secondary intention.

Decision making becomes more difficult when there is exposed bone (or in children, exposed cartilage) (see Allen Type II in the above illustration), or when there is underlying nail bed injury or associated fracture. Bone shortening can often be used to obtain soft tissue closure. However, as the bone is shortened, nail bed deformity can occur due to the loss of that support. A good "rule of thumb" is that the distal phalangeal tuft ends at, or very near to, the distal free nail margin. The distal nail margin is that tissue preventing passage of manicure instruments under the nail in the proximal direction (i.e. under the hyponychium). Amputation or nail bed injuries that occur proximal to this margin will involve bone substance of the distal phalanx. Nail plates (that overlie the periosteum of the distal phalanx) that have lost 50 percent of their substance are usually not desirable, even after extensive soft tissue reconstruction. A number of local flaps are available to cover defects with exposed bone and involvement of the nail plate. These techniques involve analysis of multiple clinical factors and are too numerous to mention here.

For now, it can be said that the final result of fingertip injuries should be a sensible pulp pad that is durable and can participate in the functions of normal fingertips; pinch, push, and hand grip functions. In the process of obtaining this objective, infection must be avoided by means of early and aggressive debridement of contaminated wounds and open fractures. This goal can also be met by early recognition of occult injuries of the deeper bone and joint structures, which often accompany high energy fingertip injuries such as those inflicted by lawn mowers.

Allen's levels of amputation to the fingertips.

When involvement of the nail plate is at or near the germinal matrix (marked by the lunula of the nail, Allen Type III) or proximal to the nail plate (Allen Type IV), then distal interphalangeal (DIP) disarticulation/amputation must be considered. Removal of the metaphysis of the proximal phalanx causes loss of full flexor digitorum profundus (FDP) muscle function to that finger. Revision to this level may provide a patient a quick recovery. For these patents, this procedure provides a durable fingertip in the simplest fashion and shortest time period of healing.

Mower blade amputation.

Water Sports Injuries

Fishhooks are not unique to the summer months, but the expansion of the fishing population is. Fishhooks come in all shapes, sizes, and degrees of sharpness. Their design is an effective one, often leaving the 'hooked' victim attached to the lure or bait, that they would rather have had hooked into a fish.

There are two common methods of extraction employed in hook penetration wounds (excluding the eyes or eyelid, ear pinna, nostril, or genitalia). The most well-known but most invasive technique takes the point or barb of the buried hook and advances or passes the barb subcutaneously through the adjacent skin. When the barb pushes through the skin's surface, the barb is cut and removed, thereby allowing easy removal of the now barbless hook from its initial resting position. This method requires further penetration, a second puncture wound, and passage of an already grossly contaminated shank of the hook deeper into the skin.

Another method, which is widely used in the fishing industry of the Pacific Northwest and previously described in the Family Practice literature (Bryan, 1981), is one that employs string traction and extraction. This method uses a small piece of twine or umbilical tape to free the victim of his/her unexpected catch.

Pressure is applied to depress the shank of the hook. The traction line is aligned in a direction of pull, parallel to but in the opposite direction of the eye of the shank. The line is then snapped or jerked in a clean crisp fashion with close attention paid to the direction of pull. Local infiltration of anesthetic is recommended so that the wound can be opened, cleaned, and left open. (Note: caution is again advised in regards to using this method on fragile appendages such as the ear pinna, nostril, genitalia, or the delicate tissues around the eye). Leaving a minor hand or finger wound open is effective in skin wounds, as healing by secondary intention is both rapid and efficient.

Boating injuries involving propellers can inflict major trauma to the head, neck, abdomen, hand, as well as the upper and lower extremities. Prompt debridement and surgical care utilizing appropriate prophylactic antibiotics, which include those effective against pseudomonas species, is of paramount importance. These are prescribed for patients who sustain open fractures, that may be infected by the normal water flora.

Ski rope injuries to the upper extremity are not uncommon occurrences in lakes and rivers. These circular avulsion injuries to the hand or digits often require microsurgical revascularization. Such tissues are injured in a circumferential fashion as the ski rope constricts about the structure (i.e. arm, leg), and the boat accelerates to pull the skier with tremendous force. While these avulsion injuries do not preclude direct replantation, this type of injury may be so severe as to warrant other means of surgical reconstruction. The common pattern or level of injury includes a fracture through or a disarticulation of the interphalangeal (IP) joint. Tendons are avulsed at the musculotendinous junction in the forearm and often remain intact, dangling from the amputated part.

The thumb is the digit most commonly injured in this fashion. Vascular avulsion occurs at or near the base of the thumb causing segments of endothelial traction injury to the vessels. Soft tissue avulsion can occur at any level and may involve a degree of crush injury caused by the rope's constrictive force. Replantation or reattachment of the thumb is desirable in order to allow the victim better grasping and pinching functions. A prosthetic thumb replacement provides some degree of function, but it is obviously devoid of normal touch sensations.

Snake Bites

With warm weather comes hiking, camping, and exploration of forests and woods in Indiana. Many mammals and reptiles come into close contact with humans during this time, and may bite the individual when approached or threatened. One creature in particular, the copperhead (pit viper subfamily of Crotalinae) is most prevalent in the southern part of the state, and can produce a dangerous, usually nonlethal, envenomation. Approximately 45,000 snake bites are reported in the U.S. per year, yet only 8,000 are from the poisonous species, and only 9-15 fatalities occur overall (Gold, 1944).

Controversy exists in regards to the initial care of a snake bite victim. However, immediate evacuation of the bite victim to the nearest medical facility is the most important method of first aid. Snake classification, if possible, is also helpful. Generally, when care can be administered, it is agreed that splint immobilization and elevation of the bitten part above the level of the heart is indicated. Systemic signs of toxicity should be immediately identified. Local treatment of the wound(s) with ice, tourniquet, electric shock, and/or crosscuts have not proven to be effective, due to the possibility of producing even more injury (i.e. crosscuts may lead to laceration). Instead, a decrease in motion will slow the flow of blood from the puncture site to the heart. In the Emergency Room, systemic data is analyzed to detect effects of the neurocardiotoxins and blood coagulation disorders. Local wounds are observed for any possibility of secondary infection or tissue necrosis. Snake bites, just as other animal bites, can be contaminated with clostridia, micrococci, aerobic spore-forming bacteria, and certain strains of pseudomonas.

Although snake bites may occur to various locations on the upper extremity, bites to the fingers are the most common. Local tissue necrosis can cause a significant loss of digital function, motion, or sensibility. Local dermotomy or fasciotomy of the affected digit(s) can be carried out when finger edema from the bite inhibits normal capillary circulation. As pressure from the venom-induced edema increases, the skin may reach its limit of elastic deformation. When this pressure becomes too great, the blood supply to the digit or hand may cease, or becomes severely compromised. Vascular studies such as digital plethysmography can be helpful in evaluating digital circulation in these patients. Midlateral incisions on the sides of the affected digit can be carried out to decompress or relieve this pressure on the digit's neurovascular bundle. This vascular supply is encased by the osteocutaneous septations of Grayson's and Cleland's ligaments (e.g. small soft tissue stabilizing ligaments) and the blood flow will be diminished as pressure increases. This fasciotomy will restore more normal blood flow in these severely compromised fingers, by releasing pressure in the fingers soft tissue compartments. The point to be made here is that the systemic signs of toxicity from envenomation are important to recognize and treat, as is the monitoring of local signs of wound contamination, circulatory embarrassment, and symptoms of impending tissue necrosis.

Softball Injuries

Joint injuries are by far the most common hand lesions sustained during the summer softball/baseball season. These lesions can be lumped into the categories of fractures, dislocations, subluxations, or tendon avulsions.

The resulting injury may be either a singular lesion (e.g. simple fracture) or combined lesion (e.g. a fracture-dislocation of the promixal interphalangeal (PIP) joint). Tendon avulsions that detach a significant amount of bone from the phalangeal base may destabilize the joint. A "dislocated finger," also known as a "coach's finger", may be easy to reduce. However, fractures that may accompany these dislocations may not reduce as easily. Avulsions of one or both collateral ligaments may result in instability or subluxation of the joint. Swan-neck or boutonniere deformity can occur from the tendinous avulsions that accompany volar dislocations.

As a primary or secondary health care provider for these injuries, the physicians of The Indiana Hand Center believe in obtaining radiograph(s) of the interphalangeal (PIP/DIP) joints of the affected hand. Early recognition of joint subluxations or fractures can guide proper treatment. Protection of the digit or surgical intervention can be made so as to preclude late sequelae of progressive joint subluxation. Secondary loss of soft tissue support or bony incongruity from the dislocation can be repaired. Early surgical intervention can provide the patient with a more satisfactory result than nearly all secondary (late) salvage procedures for these small joints. Suffice it to say, "dislocated" finger joints may not be "just dislocations", and radiographic documentation of the alignment and bony integrity of these important small joints is essential.

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