26.1

Injuries to the Hands and Feet

Chapter 26

Injuries to the Hands and Feet

Introduction

Combat injuries to the hands and feet differ from those of the

arms and legs in terms of mortality and morbidity. Death is rare,

but a minor wound, causing no lasting impairment if inflicted,

for example, on the thigh, can result in life-long disability when

it occurs in a hand or foot. The hands and feet have an important

commonality: an intricate combination of many small structures

that must function smoothly together.

Types of Injury

 Nonbattle injuries resulting in laceration of the hands and

crush injuries involving either the hands or feet are common.

Such crush injuries may result in compartment syndrome.

 Missile and blast injuries involving the hands and feet are

common in combat and may result in mutilating injuries with

a permanent loss of function.

The Hand

Even apparently minor wounds distal to the wrist crease

may violate tendon sheaths and joints, resulting in a

serious deep space infection. Such wounds require a high

index of suspicion for injury and a low threshold for

operative exploration.

Evaluation and Initial Management

 The casualty’s upper extremities should be exposed.

 Rings, watches, and other constrictive material must be

removed immediately.
26.2

Emergency War Surgery

 A preliminary neurologic exam should be performed and

documented.

 Vascular status of the hand should include an assessment of

radial and ulnar arteries (Allen test, Doppler, among others).

Treatment of Hand Compartment Syndrome

 The hand has 10 separate fascial compartments (4 dorsal

interossei, 3 volar interossei, the thenar muscles, the

hypothenar muscles, and the adductor pollicis [Fig. 26-1]).

Fig. 26-2. Hand fasciotomy incisions.

 A complete hand fasciotomy consists of four

incisions (shown in Fig.

26-2).

 One incision on the radial

side of the thumb metacarpal releases the thenar

compartment.

 A dorsal incision over

the index finger metacarpal is used to release

the 1st and 2nd dorsal

interossei, and to reach

ulnar-to-index finger

metacarpal and to release

the volar interossei and

adductor pollicis.

4 Dorsal + 3 Volar Interosseous Compartments

Ulna Nerve

Thenar

Compartment

Hypothenar

Compartment

Adductor

Pollicis

Compartment

Fig. 26-1. Compartments of the hand.
26.3

Injuries to the Hands and Feet

 A dorsal incision over the ring finger metacarpal is used to

release the 3rd and 4th dorsal interossei, and to reach down

along the radial aspect of the ring finger and small finger

metatarsal to release the volar interossei.

 An incision is placed at the ulnar aspect of the small finger to

release the hypothenar muscles.

 Although compartments

are not well defined in the

fingers, grossly edematous

fingers may require release

of dermal and fascial

constriction; care should

be taken to place the skin

incision away from the

neurovascular bundles

(Fig. 26-3).

Surgical Technique

Do not blindly clamp bleeding tissues because nearby

nerves may be injured. If unable to control the bleeding

with pressure, isolate the vessel under tourniquet control

and tie off or clamp under direct vision.

 General or regional (block) anesthetic is required; local

infiltration of anesthetic is inadequate. Epinephrine is never

injected into the hands or fingers.

 Although either the radial or ulnar artery may be ligated,

both should not be.

 Thorough exploration under tourniquet down to normal

tissue is mandatory to define the extent of the injury.

 Debridement removes buried foreign matter and deep

devitalized tissue.

ο Dead tissue is removed.

ο Tissue, including skin, with marginal or questionable

viability is left for subsequent evaluation to improve

chances for optimal outcome.

 The fingers are not amputated unless irretrievably mangled.

Fig. 26-3. Incisions for finger

fasciotomy.
26.4

Emergency War Surgery

 Viable tissue, even though nonfunctional, is retained and

stabilized for later reconstruction.

 Provisional stabilization of fractures with Kirscher wires (Kwires) may enhance patient comfort and later management.

Specific Tissue Management

 Bone: Unless extruding from the body or severely contaminated, fragments should be left in place. At forward hospitals,

only small K-wires should be used for internal fixation.

 Tendon: Minimal excision of tendons should occur. No

attempt at repair should be made in the field.

 Nerve: Do not excise nerve tissue. No attempt at repair should

be made in the field.

 The ends of lacerated nerves and tendons may be tagged with

4-0 suture so that they may be more easily identified later

during definitive reconstruction and repair.

Closure of wounds is delayed; however, exposed tendon,

bone, and joint should be covered with viable skin, if

possible, to prevent desiccation.

Dressing and Splinting

Splint the hand in the safe position (Fig. 26-4). The wrist

is extended 20°, the metacarpalphangeal joints are flexed

70°–90° and the fingers (proximal and distal interphangeal joints) are in full extension.

 Fine mesh gauze is first laid on

the wounds and covered with a

generous layer of fluffed gauze.

 The entire wound should be

covered but the fingertips left

exposed, if possible, to evaluate perfusion.

Fig. 26-4. Hand splint position.
26.5

Injuries to the Hands and Feet

 A splint is applied, immobilizing all injured parts and

extending one bone or joint beyond. A palmar plaster slab is

routine, but a dorsal one may be added for additional stability.

The Foot

Penetrating injuries of the foot frequently result in prolonged

morbidity and disability. Crush injuries and injuries from blast

are more likely to result in an unsatisfactory result than are

wounds made by low-velocity bullets or isolated fragments. This

is especially true when there is loss of the heel-pad, significant

neurovascular injury or when the deep plantar space has been

contaminated. The ultimate goal of treatment of these injuries

is a relatively pain free, plantigrade foot with intact plantar

sensation.

Evaluation and Initial Management

 The zone of injury with both open and closed injuries of the

foot is often more extensive than is apparent with the initial

inspection.

 The vascular status of the foot should be assessed by

palpation of the dorsalis pedis and posterior tibial pulses.

An assessment of capillary refill in the toes should also be

made as a compartment syndrome of the foot can coexist with

intact pulses.

 Anesthesia of the plantar aspect of the foot indicates an injury

to the posterior tibial nerve or one of its major branches and

portends a poor prognosis for a satisfactory outcome.

 Compartment syndrome of the foot can occur even in the

presence of an open foot injury, and when identified, requires

emergency treatment.

 At the time of debridement, small, contaminated bone

fragments without soft tissue attachment should be removed.

 High-volume irrigation for all open wounds is mandatory.

All wounds should be left open.
26.6

Emergency War Surgery

Injuries to the Hindfoot

 Severely comminuted, open fractures of the talus may require

talectomy, but this decision should be left to higher levels of

care.

 The talus is best debrided through an anterolateral approach

to the ankle extended to the base of the 4th metatarsal.

 Penetrating wounds into the plantar aspect of the heel pad

can be approached through a heel-splitting incision to avoid

excessive undermining of this specialized skin.

 Transverse gunshot wounds of the hindfoot are best managed

by medial and lateral incisions with the majority of surgery

performed laterally to avoid medial neurovascular structure.

Injuries to the Midfoot

 Tarsal and metatarsals are best approached through dorsal

longitudinal incisions. In addition, compartment release can

be adequately performed through longitudinal incisions

medial to the 2nd metatarsal and lateral to the 4th metatarsal

in order to leave a wide skin bridge.

 Contamination of the deep plantar compartments of the foot

is best managed through a plantar medial incision that begins

1 inch proximal and 1 inch posterior to the medial malleolus

and extends across the medial arch ending on the plantar

surface between the 2nd and 3rd metatarsal heads. The medial

neurovascular structures must be identified during this

approach. A full compartment release can also be performed

through this incision.

Injuries to the Toes

 Every effort should be made to preserve the great toe.

 Amputation of the lateral toes is generally well-tolerated.

Foot Compartment Syndrome

 There are 5 compartments in the foot.

ο The interosseous compartment is bounded by the lateral

1st metatarsal medially, metatarsals and dorsal interossous

fascia dorsally, and the plantar interosseous fascia

plantarly.
26.7

Injuries to the Hands and Feet

ο The lateral compartment is bounded by the 5th metatarsal

shaft dorsally, the plantar aponeurosis laterally, and the

intermuscular septum medially.

ο The central compartment is bounded by the intramuscular

septum laterally and medially, the interosseous fascia

dorsally, and the plantar aponeurosis plantarly.

ο The medial compartment is bounded by the inferior surface of the 1st metatarsal dorsally, the plantar aponeurosis

extension medially, and the intramuscular septum laterally.

ο The calcaneal compartment contains the quadratus plantae

muscle.

 The foot may be released through a double dorsal incision.

 One incision placed slightly medial to the 2nd metatarsal,

reaching between the 1st and 2nd metatarsals into the medial

compartment, and between the 2nd and 3rd metatarsals, into

the central compartment (Fig. 26-5).

 A second dorsal incision is made just lateral to 4th metatarsal,

reaching between 4th and 5th metatarsals into the lateral

compartment.

 To spare the dorsal soft tissue, a single incision medial

fasciotomy may be used.

Dorsal Interosseous Compartments

Medial

Compartments

Central

Lateral

Compartments

Fig. 26-5. Interosseous compartment releases through two dorsal

incisions.
26.8

Emergency War Surgery

 A medial approach to the foot is made through the medial

compartment, reaching across the central compartment into

the interosseous compartment dorsally and lateral compartment releasing all the away across the foot (see description

in this chapter’s Injuries to the Midfoot and Fig. 26-6).

 Fasciotomy wound management.

ο Following the fasciotomy, the fasciotomy wound undergoes

primary surgical wound management; all devitalized

tissue is removed.

ο As with all battle wounds, the fasciotomy is left open and

is covered with a sterile dressing.

Interosseous

Lateral

Central

Medial

Fig. 26-6. Central compartment releases through medial approach.

Stabilization

 K-wires can be utilized for temporary stabilization.

 A bivalved cast or splint is adequate for transport to a site of

more definitive care.