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Flashcards in 2 - Digital Trauma Deck (34):
1

Objectives for digital trauma

- Recognize and understand basic principles of nail trauma and digital fractures.
- Recognize the mechanisms of injury and make appropriate treatment recommendations

2

Topics in digital trauma

- Emergent Care
- History
- Physical Exam
- X-rays
- Lab
- Treatment

3

Mechanism of trauma

- Mechanism of trauma is usually direct or indirect trauma most commonly caused by falling objects or stubbing injuries.

4

Sagittal plane digital injury

- Most frequently observed
- Direct trauma, injury 2nd hyperextension or hyperflexion
- Comminuted type injury

5

Transverse plane digital injury

- Very frequent
- Abduction - adduction force
- Results in transverse or short oblique fractures

6

Frontal plane digital injury

- Least frequent
- Predominantly transverse or sagittal plane
- Injury with assoc. rotational or inversion - eversion injuries

7

Clinical presentation of digital trauma

- Acute Pain
- Discomfort with shoe gear & ambulating
- Ecchymosis and edema present within 2-3 hours
- May see dislocation

8

Digital fractures

- Fractures of all proximal phalanges are usually oblique or comminuted.
- Transverse pathologic fractures may occur in diseased bone

9

Treatment of digital injuries ***Closed injuries***

- R.I.C.E.
- Closed Reduction
- Immobilization

10

Treatment of digital injuries ***Closed reduction***

- Distraction of the digit or fracture, then put it back into alignment
- Then splint or wrap it to keep it in place
- The point of this is to achieve correct alignment of the fracture line before the initiation of bone healing

11

Treatment of digital injuries ***Open injuries***

- Surgical emergency
- Assess neuro-vascular status
- Tetanus & antibiotics if indicated
- Address soft tissue initially
- Address fracture secondary

12

Sesamoid fractures

- Not very common
- Need to rule out bifurcate or bipartite
- A mis-step may lead to soft tissue injury of the sesamoids
- Commonly sagittal plane injuries
- Crush injury (comminuted)

13

Predisposing factors to sesamoid fractures

- Cavus foot
- Metatarsus primus equinus
- Sport activities (repetitive flexion trauma)
- High-heeled shoes

14

Clinical presentation of sesamoid fractures

- Acute or chronic pain
- Edema & ecchymosis
- Pain w/weightbearing or dorsiflexion

15

Treatment of sesamoid fractures

- Radiographs
- Relieving direct or indirect pressure
- Surgical intervention

16

CASE STUDY 1
- A 27 year old female gives the history of kicking a dog gate while upset and inebriated

What is the mechanism of injury?
o Oblique fracture

What should be considered when treatment this injury?
o Comminuted, displaced intra-articular fracture

Why surgical intervention vs conservative treatment?
o Surgical intervention with fixation is the best treatment option due to the comminuted displaced intra-articular fracture
o The patient is young and healthy, so she is a good candidate for surgery

17

CASE STUDY 2
- 35 year old female presents in the office with a painful right 2nd toe
- Patient gives a history of running 10 miles, but started feeling pain in the toe after 6 miles
- There is a hematoma present under the skin at the proximal nail

- There is redness and swelling, likely due to mechanical trauma, but infection is a possibility
- If the patient presents with this the day of or after the run, it is likely from mechanical trauma
- If the patient presents 3-5 days after the run, it is more likely to be an infection and you could start an antibiotic
- Culture is not necessary in a young healthy patient and prophylactic antibiotics can be started without culture, but if there is an odor or more than blood in the drainage from the hematoma

18

CASE STUDY 3
- Open fracture of 1st left digit with exposed bone

- Need to look for intact vasculature to determine whether or not you can save the digit
- Cap fill time will give the most information on whether or not blood supply is present in the digit

19

Nail anatomy

- Nail matrix
- Nail root
- Cuticle
- Nail plate
- Distal edge of nail plate
- Hyponychium
- Nail bed

20

***MALAY CLASSIFICATION SYSTEM***

A = Primary onycholysis
B = Subungual hematoma
C = Simple nail bed laceration
D = Complex nail bed laceration
E = Nail bed laceration with phalangeal fracture

21

A = Primary onycholysis

- Separation of nail plate
- Posterior nail fold friction injury (bleeding and sepsis)

22

Treatment of onycholysis (A)

- Removal of nail plate
- Antisepsis
- Antibiotics as needed

23

B = Subungual hematoma

- Blood clot
- Must check for fractures
- Treat injury as an open fracture

24

Treatment of subungual hematoma (B)

- X-rays
- Removal

25

C = Simple nail bed laceration treatment

- Antibiotics
- Tetanus
- Surgical cleansing and irrigation
- Align the root and nail bed (repair w/ 6.0 absorbable on a traumatic
- Nail plate may be reused if avulsed

26

D = Complex nail bed laceration

- Same as simple laceration with proximal nail fold defect

27

Complex nail bed laceration treatment (D)

- Addition of a rotational flap

28

E = Nail bed laceration with phalangeal fracture treatment

- Same as complex laceration with reduction of subungual fractures
- Removal of bone spicules and nail fragments

29

Level of tissue loss

- Zone I: Distal to bony phalanx
- Zone II: Distal to the lunula
- Zone III: Proximal to distal end of lunula

30

Directional planes of tissue loss

- Dorsal (oblique)
- Transverse
- Plantar (oblique)
- Axial (tibial or fibular oblique)
- Central (Gouge)

31

Treatment of zone I injuries

- Allow wound to granulate
- STSG or FTSG

32

Treatment of zone II injuries

- Pedicle flaps (direction or plane of injury dictates type of flap)
- Atasoy - type plantar
- Kutler - type biaxial

33

Look at pictures and know these types of closure flaps

- Atasoy plantar V-Y
- Atasoy-type plantar V-Y
- Kutler type bi-axial V-Y

34

Treatment of zone III injuries

- Requires primary amputation
- Possible preservation of distal interphalangeal of interphalangeal joint