Management of acute nerve injuries of the hand

Acute nerve injuries of the hand are common and demand a methodical approach to their assessment and management. The decision to explore a hand wound is generally made based on careful clinical assessment. Different repair and reconstructive techniques are employed depending on the mechanism of injury, the type of nerve injured, the length of any defect and the timing of surgery. This article aims to provide a current review of the principles of nerve repair and reconstruction in the hand.     

(vi) Management of acute nerve injuries of the hand

Acute nerve injuries of the hand demand careful consideration and management to ensure an optimal outcome. Appreciation of the neural anatomy of the hand and its variations is fundamental to the diagnosis and subsequent treatment of any sensory or motor deficit. In this article, the principles of managing acute nerve injuries of the hand are reviewed, focussing on the relevant anatomy, key features of assessment, and principles of treatment including nerve repair and grafting.     

Management of acute ankle ligament injuries

Ankle sprains are amongst the most common injuries presenting to emergency departments in the UK. They are not one single entity but a heterogeneous group of injuries with a wide spectrum of severity. Most injuries will involve the lateral ankle ligament complex but it is important to ensure injuries to the syndesmotic ligaments or the deltoid ligaments are not missed. Missed injuries or poor management can cause disabling consequences and may occur in as many as 40% of inadequately treated patients. This article focuses on the basic anatomy and biomechanics of the ankle joint, common mechanisms of injury, appropriate diagnostic techniques and the indications for non-operative and operative management.     

Pediatric hand treadmill injuries

The great popularity of physical fitness in modern society has brought many pieces of exercise equipment into our homes for convenience and privacy. This trend has come with an increasing rate of injuries to children who curiously touch moving parts, including treadmill belts. Experience with a recent series of treadmill contact burns to children's hands is described in this article. A retrospective chart review at a tertiary referral center from June 1998 until June 2001 found six children sustaining hand burns from treadmills. The patients' ages at presentation ranged from 15 to 45 months (average of 31 months, three boys and three girls). All injuries occurred in the home while a parent was using the treadmill. Burns involved the palmar aspect of the hand, mostly confined to the fingers, and the severity ranged from partialto full-thickness burns. All patients were initially managed with collagenase and bacitracin zinc/polymyxin B powder dressings to second- and third-degree burns, along with splinting and range-of-motion exercises. Two patients required skin grafting at 2 weeks and 2 months for full-thickness tissue loss and tight joint contracture, respectively. At an average follow-up of 12 months, all patients had full range of motion and no physical limitation. The rate of children injured by exercise equipment is expected to increase. Friction burns to the hands remain a concern, although early recognition and appropriate management are associated with excellent functional outcomes. Protective modification of exercise machines seems to be the best approach to eliminating these injuries.     

Ligament injuries of the hand

Ligament injuries of the hand are fairly common. Most of these injuries are diagnosed clinically. Clinicians must have awareness and diagnostic skills to identify these injuries accurately and without delay. This is key to achieving the best possible outcome from these injuries. This article presents a succinct summary of current concepts and management principles of these injuries.     

(ii) Management of acute fractures of the hand

Fractures of the metacarpals and phalanges are the commonest fractures of the upper limb. They can be incapacitating if not treated appropriately. Hand fractures can be complicated by deformity as a result of inadequate treatment, or stiffness from overzealous treatment, leading to poor results. It is important for the treating surgeon to diagnose and understand the management of these fractures. Immediate mobilization after adequate stabilization is the key to treating hand fractures. A comprehensive review of hand fracture management is outlined in this paper.     

Management of acute open flexor tendon injuries of the hand and wrist: basic sciences,surgical factors and rehabilitation pertinent to optimizing outcome

Flexor tendon injuries to the hand and wrist represent a significant resource burden to the UK NHS. A good understanding of tendon basic science and repair techniques is crucial for the surgeon undertaking their repair and rehabilitation. Furthermore, this is a common topic assessed in the FRCS(Orth) examination. This article will summarize the basic science relating to tendon structure, physiology and injury. Additionally, it will present key surgical and rehabilitation factors relevant to clinical outcomes.     

(v) Ligament injuries of the hand

Ligamentous injuries of the digital joints of the hand can give rise to significant disability. While many can be managed conservatively, operative treatment is often necessary, particularly in complete ligamentous ruptures and late presenting cases. This article describes the management of the commoner and less common injuries.     

Management of maxillofacial injuries in Iraq

These clinical studies reflect the experience of the author in managing 673 patients treated during the last 8 years. All patients were treated in the Maxillofacial Unit, Surgical Specialties Hospital, Medical City, Baghdad, and in the author's private clinic. Included patients were 530 males and 143 females; patients' age ranged between 1 year and 75 years (mean, 38 y). Distribution of injuries was as follows: fracture of the mandible, 287 (42.64%); middle third injuries, 39 (5.79%); orbital injuries, 236 (35.07%; including 12 cases with cranioorbital injuries); injuries in children, 27 (4.0%); fracture of the zygoma, 52 (7.73%); and fracture of the nose, 40 (5.94%).Maxillofacial injuries in this study were classified as follows: (1) craniomaxillofacial with head injuries and cerebrospinal fluid leak; (2) fracture of the middle third including Le Fort I, II, and III and midline split in the face; (3) fracture of the mandible as an isolated injury or as part of a facial skeleton injury; and (4) isolated complex injuries of the zygoma, the orbital skeleton, and the nasoethmoidal region.The technique used for treating middle third injuries was external fixation either by halo frame (with vertical rods and cheek wires) or by box frame (using 4 external pins connected by rods) or internal fixation by suspending the middle third with internal wires (0.5 mm stainless steel) from the zygomatic process of the frontal bone beneath the zygomatic arch down the lower arch bar. Fractures of the mandible were treated by gunning splint with intermaxillary fixation (IMF) or with open reduction and fixation by stainless steel wire with IMF or by IMF screw or by an arch bar and IMF. Other fractures such as fracture of the orbit were treated by bone graft, sialastic, or lyophilized dura with open reduction. Fractures of the zygoma were treated by open reduction and fixation with stainless steel wire and bone graft or by reduction without fixation. Fractures of the nose were treated by reduction with straightening of the septum with a splint (lead splint or polythene) or by external splint with plaster of Paris. With the techniques used, results from managing these cases were satisfactory.     

Management of parotid duct injuries

Injuries to the buccal region of the face can carry multiple complications due to the complex anatomy that lies within. The facial nerve and the parotid duct can be easily injured by sharp or penetrating trauma to the cheek. The purpose of this paper is to present the full spectrum of current treatment modalities available to manage these injuries. The anatomy of the parotid gland and duct are described, and surgical techniques and therapeutic alternatives for the immediate and delayed treatment of the parotid duct injuries are reviewed. Clinical cases are presented to illustrate the treatment options outlined.     

Management of intrusive luxation injuries

Abstract Traumatic intrusion of permanent teeth is a relatively infrequent but serious type of dental injury, cine to the complicated picture it involves. Various treatment approaches have been suggested, so far, regarding management of intrusive luxation. Techniques aiming to reposition the intruded tooth include observation for spontaneous reeruption, surgical as well as orthodontic repositioning. However, development of complications such as pulp necrosis, inflammatory root resorption, replacement resolution and ankylosis and loss of marginal bone support makes selection of the most favorable technique controversial. In this paper, a critical review of the existing treatment modalities is attempted and treatment approaches based on diagnostic parameters that are indicative of the severity of an intrusive injury are presented. Recommendations are made after taking into consideration experimental and clinical study findings and observations from other author's and our own clinical experience. Two cases of intrusive luxation in children are presented and management of the dental injuries as well as the complications which occured are being discussed.     

Management of sport-related maxillofacial injuries

By analyzing sports-related maxillofacial fractures, we sought to describe preventive measures and recovery times until sporting activities could be resumed. Between January 2001 and December 2006, 1241 patients were hospitalized as a result of maxillofacial fractures. The patients with sports-related maxillofacial fractures were analyzed based on age, sex, type of sport, injury mechanism, trauma site, presence of associated fractures, hospitalization, treatment method, and recovery time until the resumption of sporting activities. One hundred thirty-eight patients (11.4%) sustained sports-related maxillofacial fractures: 121 males and 17 females (ratio 8:1), aged between 11 and 72 years. The sport producing the greatest number of injuries was soccer (62.3%), followed by skiing (14.5%), and horseback riding (6.5%). The injuries involved mainly the middle third of the face (71.6%), and the mandible was the most affected site (27.2%), followed by the maxillary-zygomatic-orbital complex (25.9%). Treatment was surgery in 93.5% of the patients, with an average hospitalization period of 3.5 days. The protocol created to manage the follow-up of maxillofacial injury patients advised resuming sports activities at least 40 days after the trauma, except in the case of combat sports, when a period of 3 months was required. Although the results of this study indicate a reduction in the total incidence of sports-related maxillofacial injuries, they also show an alarming secondary increase in trauma resulting from the most popular sport in Italy-soccer. Therefore, stricter regulations are needed to discourage violent play, rather than relying on the use of protective equipment. Moreover, patients should be advised when they can resume sports activities, particularly in the case of professionals and semiprofessionals.     

Orofacial/cerebral injuries and the use of mouthguards by professional athletes in Switzerland

Abstract –  The objective of the present study was to measure the occurrence of orofacial and cerebral injuries in different sports and to survey the awareness of athletes and officials concerning the use of mouthguards during sport activities. Two hundred and sixty-seven professional athletes and 63 officials participating in soccer, handball, basketball and ice hockey were interviewed. The frequency of orofacial and cerebral trauma during sport practice was recorded and the reason for using and not using mouthguards was assessed. A great difference in orofacial and cerebral injuries was found when comparing the different kinds of sports and comparing athletes with or without mouthguards. 45% of the players had suffered injuries when not wearing mouthguards. Most injuries were found in ice hockey, (59%), whereas only 24% of the soccer players suffered injuries when not wearing mouthguards. Sixty-eight percentage of the players wearing mouthguards had never suffered any orofacial and cerebral injuries. Two hundred and twenty-four athletes (84%) did not use a mouthguard despite general acceptance by 150 athletes (56%). Although the awareness of mouthguards among officials was very high (59%), only 25% of them would support the funding of mouthguards and 5% would enforce regulations. Athletes as well as coaches should be informed about the high risk of oral injuries when performing contact sports. Doctors and dentists need to recommend a more intensive education of students in sports medicine and sports dentistry, and to increase their willingness to become a team dentist.     

Management of traumatic facial injuries

Whether minor or major, traumatic injuries to the maxillofacial area have far-reaching physical and emotional effects. Because the dentition dictates facial form and function, the oral and maxillofacial surgeon, a dental specialist with a minimum of four years of hospital-based surgical training, is uniquely qualified to manage these injuries. At times, the expertise of the general dentist and other dental specialists may be needed to provide definitive care. Several cases are provided to illustrate management of facial trauma.     

Acute nerve injuries in the hand: common patterns and treatment strategies

Acute nerve injuries in the hand are common. Mechanisms of injury vary and include sharp transection, direct and indirect blunt trauma resulting in contusions and traction injuries respectively, ischaemic and compression injuries and chemical, thermal or electrical injury. Sharp, penetrating injuries are the most common, with patients typically presenting after a laceration with glass or a knife. Both blunt and sharp injuries can be associated with bony injuries as well as injury to the vascular and tendinous structures. The management principles of nerve injuries in the hand follow those of nerve injuries elsewhere, however the distal nature of the injuries often means that some treatment strategies are less applicable. In this article we will discuss the basic structure of nerves as well as the anatomy of the peripheral nerves in the hand, followed by the treatment strategies that can be employed to address acute nerve injuries in the hand.