General complications of hand injury
Severe hand injuries are most often due to crush or rotating blade mechanism, and are best treated by a hand surgery specialist (CO). Such injuries usually involve all organ systems of the hand and are always associated with complications. Treatment principles and initial management which may be adequate for lesser injuries may be inadequate in the management of a mangled hand (DI). Intervention by a specialist reduces the duration and extent of disability as well as reducing the overall care requirements and cost for care in severe extremity trauma.
Scar contracture: Contractures due to skin scarring are more likely to be a problem if scars extend longitudinally across the flexor surface of a joint. Scar contractures in severe cases may develop over the first few weeks after injury, but in many cases progress over the course of months. In the growing child, scar contractures may lead to progressive growth disturbances. Stiffness and contractures due to mechanical changes in joints and tendons, as discussed above, may develop independently.
Cosmetic deformity: The immature scar may be hypertrophic: thick, red, and raised. These changes usually resolve gradually over the course of a year, although the process may take longer in young children. Permanent visible deformity from hyperpigmentation, thin stretched scars over extensor surfaces, and tight scar bands across flexor surfaces may all be troublesome. Fingernail deformities are common after lacerations and crush injuries in the area of the nailbed. The most common problems are split nail from nailbed injury and hook nail deformity from loss of the tuft of the distal phalanx in a fingertip amputation. Such problems are sometimes unavoidable, but the best prevention is meticulous anatomic repair of nailbed lacerations. Once established, fingernail deformities may be difficult or impossible to correct.
Complex regional pain syndrome: (rsd.htm, tipsrsd.htm) Complex regional pain syndrome, previously known as reflex sympathetic dystrophy, algodystrophy, sympathetic maintained pain, Sudeck's atrophy and other names may develop after any hand injury, particularly when associated with nerve injury or irritation. This problem may occur spontaneously, after major or minor injury. It variably involves spontaneous burning pain, hyperalgesia, swelling, vasomotor disturbances, disuse, and exacerbations by movement. Although there may be spontaneous resolution, the majority of patients develop some degree of chronic symptoms such as pain, stiffness, and difficulty with normal use of the hand despite all available treatment (EF). Best results of treatment require early recognition, aggressive medical therapy, and elimination of triggering phenomena. Medical therapy may involve sympathetic nerve blocks, gabapentin or other medications, and biofeedback. Triggers known to aggravate the condition include peripheral nerve irritation from neuroma or compressive neuropathy, aggressive passive range of motion in therapy, and dynamic hand splinting. The effects of complex regional pain syndrome may be far more disabling than the initial injury.
Dysfunctional use: Patients may develop maladaptive patterns of use after injury, ranging from awkward positioning to complete disuse of the hand. This is often due to unconscious reflex protective mechanisms, and may be difficult to correct. Extensor habitus refers to the tendency for the injured index finger or small finger to be held in extension. This unconscious posturing is powered by the independent extensor of the finger, and is best treated by early recognition and buddy taping. Alien hand syndrome refers to a complete disuse of the hand accompanied by a perception by the patient that the hand is "not theirs". Such problems may also be factitious, but labeling them as such does not improve the overall outcome.
Compartment syndrome
of the hand may develop after crush injury, reperfusion following fracture
related ischemia, intravenous injections, crush or blast injury (BB),
bleeding following fracture, arterial cannulation or regional surgery,
or due to prolonged pressure on the hand or arm. The forearm is the most
common site for compartment syndrome in the upper extremity. Compartment
syndrome of the upper extremity is more likely to develop in patients who
are obtunded. Seriously ill children who receive multiple venous and arterial
injections are also at particular risk. Treatment requires prompt recognition
and decompression of intrinsic muscle compartments as well as carpal tunnel
released in selected cases (AS). The
late consequence of compartment syndrome of the upper extremity is Volkmann's
contracture (BB, CS)
which involves both muscle contracture and local ischemic neuropathy. Ischemic
muscle contractures respond poorly to nonoperative measures such as splinting,
and requires an aggressive surgical approach using muscle slides, tendon
lengthening and tendon transfers similar to those used in the treatment
of upper extremity spasticity. Neurolysis is indicated for persistent nerve
symptoms, but outcome is unpredictable.
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