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Crush Hand?

High energy trauma

Skin

Tendon

Nerve

Vessel

Bone

  • One injury - Multiple systems

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“Layered Planning” required

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What to do first?

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Case 1

  • 12 Yr old male
  • Hand got stuck in a barbed wire while crossing compound (to fetch a ball)

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Case 1

Examine clinically

    • Contamination present
    • He is able to move MCP, PIP and DIP
      • No Tendon injury
      • No bony injury
    • Capillary refill <3 sec
      • No Vascular injury

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Case 1

Examine clinically

    • Contamination present
    • He is able to move MCP, PIP and DIP
      • No Tendon injury
      • No bony injury
    • Capillary refill <3 sec
      • No Vascular injury
  • No bony injury on the xray

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Case 1

STEP 1: Thorough Debridement

  • Healthy bleed from the skin flap
  • No tendons injured

STEP 2: Assess the damage

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STEP 3: Meticulous suturing

On table

15 days post op

1 month post op

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1 month post op

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2 months post op

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Case 3

  • 8 yr old girl
  • Cement bench in garden fell on her hand
  • Came with a dangling fingertip

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Case 3

  • 8 yr old girl
  • Cement bench in garden fell on her hand
  • Came with a dangling fingertip

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Distal phalanx tip fracture in middle finger

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Case 3

  • 8 yr old girl
  • Cement bench in garden fell on her hand
  • Came with a dangling fingertip

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Distal phalanx tip fracture in middle finger

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Case 3

STEP 1: Thorough Debridement

STEP 2: Assess the damage

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Case 3

STEP 3: Meticulous suturing

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Case 3

  • 15 days post op
  • Blackening noticed

DO NOT DO ANYTHING

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Case 3

  • 15 days post op
  • Blackening noticed

DO NOT DO ANYTHING

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Case 3

  • Scab matures in 1 month
  • Removed

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Case 3

Dead nail falls off in 2 months

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Case 3

2 months post op

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Case 4

  • 44 yr male
  • Crushed middle finger at the level of P1
  • Tendon injury

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  • Fracture

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Case 4

  • 44 yr male
  • Crushed middle finger at the level of P1

On examination:

  • Finger extension not possible actively

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  • Tendon injury

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  • Fracture

✅

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Case 4

  • Fracture of P1
  • Tendon injury

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  • Fracture

✅

✅

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Case 4

STEP 1: Thorough Debridement

  • EDC partially torn

STEP 2: Assess the damage

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Case 4

STEP 1: Thorough Debridement

STEP 2: Assess the damage

STEP 3: Fix the fracture

  • 2 antegrade cross k wires
  • Tip – Flex the MCP joint

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Case 4

STEP 1: Thorough Debridement

STEP 2: Assess the damage

STEP 3: Fix the fracture

STEP 4: Tendon repair

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Final Algorithm

Emergency

Debridement

Skeleton

Tendon

Soft tissue

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Final Algorithm

Is it salvageable?

Yes

What is Missing?

Fix each system

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Take home message

✅ Think system-by-system�✅ Prioritize coverage and length early�✅ Don’t burn bridges — delay tendon/nerve if in doubt�✅ Be honest about prognosis — function ≠ form

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Thank you