Imaging Severe Hand Trauma

Introduction

This page includes case studies and discussion on a selection of patients who presented with severe hand trauma. These cases include some technique points that may have a more general application.

Types of Injuries

Degloving

source: unknown	A degloving injury is one in which the patient's superficial tissues have been torn along superficial tissue planes in a manner akin to removing a glove.
source: unknown	This patient's finger has been amputated with an associated degloving injury. Note the injury was caused by a considerable force applied to the patient's ring (shown)
<a class="external" href="http://community.livejournal.com/morbid_oddities/13605.html" rel="nofollow" target="_blank">http://community.livejournal.com/morbid_oddities/13605.html</a>	Degloving injuries have a well deserved reputation for being particularly visually unappealing. These patients are commonly referred for radiography to assess any underlying bony injury. The radiographer has a number of challenges. from a patient care perspective, it is undesirable for the for the radiographer to be reeling at the sight of a patient's injury. It is an important part of the student's clinical placement to develop the constitution to deal professionally with this type of injury (and worse). The radiographer who instructs a student to be involved in imaging this type of injury is not necessarily motivated by bad intentions. Equally, if you consider that it is beyond you and you may deal with it poorly (including fainting), it would be prudent to advise the qualified radiographer. Blood-soaked bandaging will potentially produce considerable artifact and should be removed if possible (seek advice first). Before doing so, a number of important factors should be considered. how will you react? how will the patient/relatives react? will you do any harm? Is the injury bleeding profusely? How will you protect the cassette/IR? It is important to consider the reaction of a relative/carer/parent who might be accompanying the patient. I have seen patient's deal very well with their injuries but the relatives faint like dominoes. If you do remove the bandaging, re-apply them (or otherwise cover the would) to prevent it from drying out.
<a class="external" href="http://community.livejournal.com/morbid_oddities/13605.html" rel="nofollow" target="_blank">http://community.livejournal.com/morbid_oddities/13605.html</a>	You would normally be required to image any amputated bony anatomy (ideally, not whilst it is in the glass). It is important to label/annotate the digit (in this case), particularly if there are multiple amputations.

Severe Hand Trauma
CASE 1

Presentation

This patient presented to the Emergency Department following an accident in which the patient's hand made contact with an operating circular saw. The patient was referred for hand radiography.

Imaging

	The patient presented with a bandaged hand that looked somewhat like this one. There are very few clues as to what the exact injury is that underlies the bandage. Two important considerations are 1. Hand always comes of worse in cases of hand vs circular saw 2. One of the patient's fingers has arrived separately to the patient

What the Surgeon Wants to Know

This is without any doubt a surgical case. The surgeon will want to know what bony and joint injuries have been suffered in this accident. Any soft tissue information would be a welcome bonus.

Imaging

Image 1

Point of confusion Some would say that the thumb is not a finger and the 2nd digit is the first finger. I avoid this nonsense by either labelling the fingers as "Digits".... 1st digit, 2nd digit etc or, alternatively, use the annotation "Ring finger" etc. Don't use " pinky" for the 5th digit- "pinky" is a non-medical term!). Also, don't use the term "pointer" to refer to the index finger- the nomenclature is confusing enough. If the digit has arrived in a plastic bag, you may be able to leave it in the bag while imaging (no creases in the bag). It will commonly present in a plastic bag in an ice bucket. Positioning is largely a matter of balancing the digit in the correct position. This is not always easy.

The amputated finger was imaged first. The finger is known to be the index finger. The annotation is important- the image must be labelled with the correct side and the digit must be identified. First digit or thumb second digit or index finger third digit or middle finger fourth digit or ring finger 5th digit (don't use "pinky")

Image 2

This is the first "PA" hand image. The 4th and 5th digits appear intact, but the remainder of the digits are unclear. The radiographer has removed the outer blood-soaked bandaged but left the inner protective swabs insitu. Blood-soaked bandaging is likely to produce a very significant artifact and is generally best removed. If in doubt, ask the referring doctor if it is safe to do so. If the bandaging and swabs are removed completely, do not let the hand injuries dry out- replace moistened bandaging immediately if possible. The problem with leaving the heavy bandaging in place, is that when you complete your radiography and review your images, you realise that you haven't visualised the anatomy adequately. At this point, you or the referring doctor will probably decide that the imaging needs to be repeated with the banding off.

Image 3

This is lateralish. The thumb has a saw-cut to the proximal phalange and, once again, the 4th and 5th digits appear to have suffered no bony injury.

Image 4

The radiographer has realised that the fingers are in a flexed position and decides to position the hand such that the phalanges are parallel to the film/IR (AP ish position). The results are good for the 4th and 5th digits... once again.

---intermission----

At this point the radiographer gave up in despair. The imaging of the 4th and 5th digits had been spectacular, but the state of the other digits was not entirely clear. The referring doctor reviewed the images and decided that improved imaging was required of the first three digits. The doctor decided that a nerve block would be performed and the imaging redone with all of the bandaging off.

Image 5

This is the first redo image with all bandages off and the hand positioned with the patient experiencing no pain. The hand is in a true PA position. The difference is spectacular. You don't need to be an expert in image interpretation to see what is going on here. This is what the surgeon will want to see.

Image 6

The hand is in a conventional oblique position.

Image 7

This is a horizontal beam lateral hand image. The palmar artifact is either from the aseptic material that the hand is resting on (colloquially known as a bluey") or from a plastic coated positioning sponge.

Discussion

The point of this case study is that there were 7 images taken when there could have been four (or even 3). It could be argued that once the first image was reviewed, it was clear that the flexed fingers would mitigate against obtaining a clear view of the anatomy. The imaging following the arm-block was very successful.

Severe Hand Trauma
CASE 2

Presentation

This patient was using a router when his hand came into contact with the rotating cutter. He presented to the Emergency Department with a bandage wrapped around his hand.

Imaging

The initial PA hand image suffered from the expected finger overlap issues. Attempts to remove the bandage resulted in considerable blood loss from the fingers. The patient was returned to have the fingers bandaged individually. This approach was used because it was known that the injuries were restricted to the distal phalanges.

	The second set of images demonstrated the individual digits clearly. There are bony injuries the terminal tufts of the second, third and fourth digits. There is some artifact from the blood-soaked bandages
	The individually bandaged fingers allows the radiographer to perform PA, lateral and oblique views without overlapping the fingers.

Severe Hand Trauma
CASE 3

Presentation

This 18 month old child presented with trauma to several of his distal phalanges. These types of injuries are commonly seen in children when their fingers are caught in a door frame while the door is being closed.

Imaging

	The initial PA hand image was undertaken with bandaging insitu. This was predictably unsuccessful- a child's phalanges are thin bony structures which will have insufficient density to be imaged adequately through bandaging, particularly if it is soaked in blood.
	The PA hand image with bandaging removed demonstrates the child's phalanges successfully. There is evidence o a soft tissue injury do the tip of the middle finger. The inclusion of the adult fingers is unnecessary and should be avoided.

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