The hand has an intricate design and function, with an amazing anatomy. For humans, the hands are essential organs due to their agility and dexterity and are vital to our activities of daily living. The hand is a very complex structure and is composed of an array of small bones, totaling 27, including the eight carpal bones. In combination with this, there are the different muscles, nerves, tendons,

ligaments, and the neurovascular bundle which form a part of the machinery of the hand.[1] The hand is the most frequently injured body [1]. Injuries result from several causes and can occur at home, in road traffic accidents, in industries, in the workplace, in the field of play, in assault, or even in self-inflicted injuries [2]. Acute trauma involving the upper limb in the emergency room is common; however, it is not well understood from an epidemiological perspective [3]. Hand and forearm injuries are rarely life-threatening but carry the potential for serious handicaps with far-reaching consequences, as they are common in the productive age group. They have personal, economic, and social consequences hence considered a major social and public health problem [3]. Hand injuries are common and account for 5-10% of emergency department (ED) injuries and 4.7% of all trauma patients [5] the functional importance of closely packed structures, blood vessels, nerves, and tendons make injuries to the hand and forearm hazardous, and the careful management of paramount importance. [6, 7] Lacerations to the volar wrist surface have the potential to be severely debilitating, mainly because of the superficial location and high density of the tendons, nerves, and arteries in that area. Tendons have a relatively less inherent tendency to heal. The functional integrity of the hand requires intact neurovascular units and a stable platform in the form of a normal wrist joint [8]. The anatomy of the tendons is paradoxically more complex and the management of injuries is more varied and corresponds to the anatomical zone of injury [9]. Injuries to the bones and joints occur in the form of fractures, dislocations, or amputations. Phalangeal fractures are common injuries that may significantly affect hand function if not appropriately managed. Phalangeal fractures occur more commonly than metacarpal fractures while dislocations affect the proximal interphalangeal joint more.[9] The goal of any type of treatment for hand and forearm injury is to restore form and function. The functional importance of closely packed structures, blood vessels, nerves, and flexor and extensor tendons makes injuries in this zone very hazardous, and careful management is of paramount importance. Wound debridement, rigid internal fixation of the bone, repair of neurovascular structures, and skin coverage take precedence over tendon repair. In assessing the injured hand and forearm, several factors play a key role in determining the course of treatment [10]. The current study aimed to determine the pattern of presentation, management, and outcome of hand and forearm injuries.

This cross-sectional study was conducted in the Department of Plastic and Reconstructive Surgery, Gandhi Medical College, Secunderabad, Telangana. Institutional Ethical approval was obtained for the study. Written consent was obtained from all the participants of the study after explaining the nature of the study in vernacular language. The duration of the study was 18 months.

Inclusion criteria

1. Patients of either sex and all age groups of soft tissue injuries to the hand and forearm
2. Patients with bony injuries in association with the soft tissue injuries of the hand and forearm.

Exclusion criteria

1. Patients with healed and chronic injuries
2. Burns and post-burn contractures.
3. Congenital deformity of the involved hand
4. Isolated bony injuries of hand and forearm.

After we obtained institutional ethics and scientific committee approval and consented to the study a total of 91 patients met inclusion criteria and compliant with follow up at 3 months and 6 months were included in this study.

Management in brief

Management of hand and forearm injuries begins at the site of injury with stabilization, hemorrhage control, pain management, and care of amputated parts. The affected hand is covered, elevated, and splinted. In the emergency setting, life-threatening conditions are prioritized, followed by removal of jewelry and fluid resuscitation in cases of severe bleeding. Hemostasis is achieved through direct pressure, dressing, and elevation. Parenteral analgesia aids in evaluation.

A systematic assessment follows resuscitation. History includes age, hand dominance, occupation, past medical history, smoking status, injury details, first aid measures, and immunization status. Examination focuses on wounds, swelling, skin color, deformities, circulation (capillary refill, pulses), and sensory/motor functions. Major nerve domains are assessed, and radiographs (AP, lateral, oblique views) help identify fractures and foreign bodies. Ultrasound and Doppler detect tendon, nerve, and vessel injuries. Baseline blood tests ensure anesthesia fitness. Injury severity is determined using the Quick DASH-9 score. Treatment includes analgesia, antibiotics, tetanus prophylaxis, dressing, elevation, and surgery as needed. Follow-ups at three and six months evaluate outcomes using Quick DASH-9 scores.

Tendon Repair (Flexors & Extensors)

Surgeries were performed under brachial block, general, or combined anesthesia with tourniquet control. Debridement and wash precede tendon retrieval, freshening, and proper positioning. Repair uses modified Kessler or mattress suturing with a polypropylene core and epitenon sutures. After hemostasis, a drain is placed, wounds are closed, and splints are applied.

Arterial Repair

Peripheral vascular repair follows access, exposure, control, and repair. Temporary control is via digital pressure or a BP cuff. Blind clamping is avoided to prevent nerve injury. For combined radial and ulnar artery injuries, the ulnar artery is repaired first. Vascular anastomosis involves interrupted 8-0 polypropylene sutures with lumen flushing using heparinized saline.

Nerve Repair

Epineural Repair: Proximal neuroma and distal glioma are resected to align healthy fascicles. Performed under magnification, repair uses 10-0 polypropylene interrupted sutures. Nerve Grafting: Segmental defects >6cm require autografts, commonly using the sural nerve.

Fracture Management

Fractures are reduced and stabilized using splints, external fixators, or Kirschner wires. Non-displaced fractures receive splinting and early rehabilitation. Open, unstable, intra-articular, or irreducible fractures require operative reduction. Percutaneous K-wires stabilize displaced or unstable shaft fractures.

Flap Coverage

Exposed vital structures necessitate flap coverage. Local flaps (V-Y advancement), regional flaps (thenar, posterior interosseous artery flap), and distant pedicled flaps (abdominal, paraumbilical, louvre, groin flaps) are used based on defect size and tissue condition.

Flexor Tendon Repair: Kleinert’s protocol guides rehabilitation. Extensor Tendon Repair:

• Zones I & II (Mallet Finger): DIP joint splinting for 6-8 weeks, followed by night splinting and gradual exercises.
• Zone III (Central Slip Lesion/Boutonnière Deformity): PIP joint immobilized in extension for 6 weeks, with gradual mobilization at 6-8 weeks.
• Zone IV (Proximal Phalanx): Active gliding exercises prevent adhesions.
• Zones V & VI (MCP Joint & Dorsum of Hand): Early motion protocol with a dynamic splint, progressive MCP joint flexion allowed over 6 weeks.
• Zone VII (Extensor Retinaculum at Wrist): Early mobilization with wrist splinted in extension for 3-4 weeks, followed by gradual MCP joint release.

Rehabilitation of Thumb Extensors

Extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus injuries are managed with static or dynamic splints for 4-6 weeks, followed by progressive thumb extension exercises.

Functional Outcome Assessment

Quick DASH-9 scores assess post-treatment outcomes for hand and forearm injuries, ensuring comprehensive recovery evaluation.

A total of 91 patients were included in the study based on the inclusion and exclusion criteria. Out of this 79 (86.8%) were male and 12 (13%) were females.  The most common age group affected in the present study was 21-30 years (34.06 %) followed by 11-20 years (17.58%). The youngest patient in this study was one year old and the oldest patient was 65 years ago the mean age of the cohort was 29.5 ± 4.5 years depicted in Table 1.

Table 1: Age-wise distribution of cases included in the study

In the present study, 83(91.2%) patients presented with open wounds and 8(8.8%) of patients were with closed wounds. In present study, most commonly dominant hands were injured (74.82%) as compared to non-dominant hand injuries (24.17%) given in figure 1.

In the present study, RTA was most common cause (65.93%) of hand and forearm injuries followed by machinery (14.28%) followed by door crush injury (4.39%) kite manja injury and assault (3.29%) depicted in table 2.

Table 2: Mechanism of injury to hand in the cases of the study

In this study, Extensor Tendon Injury (ETI) was the most common type, observed in 42% of patients. Flexor Tendon Injury (FTI) followed, accounting for 24%, while crush injuries comprised 12%. Additionally, 5% of patients had combined ETI and FTI injuries given in table 3.

Table 3: showing the type of hand injury in the cases of the study

Among 61 cases of tendon repair modified Kessler suture technique was used in 58 cases. Tendon graft was sutured using pulvertaft technique in 3 cases amongst which TFL in two cases and palmaris longus in 1 case.

Table 4: Fractures of bones in hand and forearm

In the current study, a total of 12 cases of bony injury in association with soft tissue injury were noted the most common fractured bone is metacarpal accounting for 33.34% of fractures and 1 patient had distal radioulnar dislocation (Table 4). One radius fracture rush nail was applied and one more case of radius fracture external fixator was applied by the orthopedic team. One case of ulna fracture which was undisplaced splinting was done 5 Phalangeal and 4 metacarpal fractures were fixed with 1.5mm k-wires without C-arm guidance. N=9 cases of arterial injury were noted in 3 radial arteries and 6 ulnar arteries. The present study showed right-sided injuries (72.5%) more than left-sided (23%). Bilateral injuries were found in 4.3% of patients.

Table 5: Timing of surgery for the cases in the study

In the present study, the most commonly injured nerve in hand and forearm injuries was the median nerve followed by the ulnar nerve. We did not encounter radial nerve injury. Among 7 median nerve injuries 2 cases sural nerve graft was used and primary repair was done in 5 cases. Among 4 cases of ulnar nerve injury primary repair was done in all 4 cases.

Table 6: site of injuries in relation to wrist crease

In current study, most common site of injury was distal dorsal aspect to the wrist of hand and forearm given in table 6. In present study maximum no of cases were managed by suturing (64.8%), followed by flaps (23%) and SSG (12%) respectively.

 Table 7: Management of the hand injuries in the cases of the study

Table 7 shows the management of hand injuries in this study involved various treatment modalities. Suturing was the most commonly performed procedure, accounting for 64.8% of cases. Split-thickness skin Graft (SSG) was used in 12% of cases. Among flap procedures, the Inferiorly Based Abdominal Flap was the most frequently used (7.7%), followed by the Paraumbilical Flap (4.4%) and V-Y Advancement Flap (4.4%). Other flaps used included the Thenar Flap (2.2%), Superiorly Based Abdominal Flap (2.2%), Groin Flap (2.2%), Posterior Interosseous Artery Flap (1.1%), and Fillet Flap Cover (1.1%).

  Table 8: Outcomes based on site of injury in the cases of the study

Table 8 depicts the mean Quick DASH (Disabilities of the Arm, Shoulder, and Hand) score is a self-reported questionnaire that measures physical function and symptoms in individuals with musculoskeletal disorders of the upper limb. Lower scores indicate better function and less disability, while higher scores indicate greater disability. Volar (palmar) injuries may involve more critical structures and can lead to greater functional impairment and higher Quick DASH scores. The Dorsal injuries involve less critical structures or are easier to rehabilitate, resulting in better functional outcomes.  Proximal injuries heal better due to better blood supply or less strain during recovery compared to distal injuries, which are often subjected to more mechanical stress.

In this study, a total of 22 patients had complications. 9 patients had a hematoma which was drained. 6 patients had surgical site infections, 3 patients presented with skin flap margin necrosis, for which debridement and secondary suturing were done four patients presented with flap loss out of which one posterior interosseous artery flap was debrided and the hypogastric flap was given, and one case of superiorly based abdominal flap return was done, one paraumbilical flap and one hypogastric flap were debrided.

Hand and forearm injuries are complex, high-energy conditions that are challenging to manage. These require careful planning and meticulous treatment. The spectrum of traumatic hand injuries included minor soft tissue injuries and fractures to complex injuries requiring nerve, tendon, or artery repair within this spectrum, which are quite common and reported in 54.8% of patients with a small laceration and 92.5% of patients with a deep injury through a small laceration. [11] Thus, the treating surgeon needs to recognize that even a small laceration to the hand may involve the flexor or extensor mechanism. This study was performed over 18 months (May 2022–October 2023), during which 91 patients presented with hand and forearm injuries. The mean age of the patients in the present study was 29.92 compared to 37.17 which was reported by Karabeg et al. [12]

This study included 79 (87%) male and 12(13%) female patients, which was similar to the results of a study by Karabeg et al. [12] According to their study, 87.8% of male patients and 12.2% of female patients were included, which showed a male preponderance. These data are consistent with epidemiological data from other authors, such as Bajracharya et al. [13] and Starčević B et al. [14] the high percentage of male patients’ affection can be explained by the work-related activities and RTA that male patients participate in. In the present study, the most common hand injuries were injuries (74.82%) as compared to non-dominant hand injuries (24.17%), which was in agreement with the study conducted by Bajracharya et al. [13] In the present study, RTA was the most common cause (65.93%) of hand and forearm injuries, followed by machinery (14.28%) and door crush injuries (4.39%). Similar results were seen in a study conducted by Samal B et al. [15] however in studies conducted by Bajrachary et al. [13] and Bisht et al. [16] machinery and workplace injuries were commonest respectively In the current study, the most common type of injury was noted is ETI which accounted for 42% of patients, followed by FTI and crush injuries which accounted for 24% and 12% respectively which was similar to Starčević B et al. [14] Present study also emphasized right-sided injuries (72.5%) more than left-sided (23%). This indicates that right-handed dominance is common, and injuries of the dominant hand are more frequent than those of the non-dominant hand.

In the present study, metacarpal bone was the most common bone fracture, and fractures were observed in 12.08% of cases. Gupta et al. [17] noted that 25.61% of the patients had associated fractures. In the present study, the most commonly injured nerve in hand and forearm injuries was the median nerve, followed by the ulnar nerve, which was in accordance with studies conducted by Samal et al. [15] in which the maximum number of cases was managed by suturing (64.8%), followed by flaps (23%), and SSG (12%). Similar results were reported in a study conducted by Ravi Kumar et al. [18] in which 22 patients had complications. Nine patients had drained hematomas. Six patients had surgical site infections, and three patients presented with skin flap margin necrosis. In a study conducted by Ravi Kumar et al. [18] wound infection was the most common complication, followed by edema and skin necrosis. In the present study, 60.4% of patients had less than 5 days of hospital stay, 39.6% of patients had more than 5 days of hospital stay, and the length of hospital stay increased with the severity of injury.

In the present study, 74.7% of patients underwent surgery within 3 days of admission, and 23.3 % beyond 3 days. In this study, we used the Quick DASH 9 score to assess functional outcomes after a hand injury. The mean Quick DASH 9 score was 32.8 at the time of admission. In a study conducted by Samal B et al. [15] mean score was 51.24±9.89. The outcome of the scores represented that the majority of participants were found under the range 0 -30 (mild severity) with 94.5%, followed by 31-65 (moderate severity) with 5.4% by the end of 6 months followed up period No epidemiological data was available for hand injuries studies using Quick DASH 9 score for comparison, however in a study conducted by Gabel et al. [20] the modified Quick DASH-9 is a valid outcome instrument for upper limb function evaluation.

In this study, most patients were males who sustained workplace injuries, with the younger age group (20–40 years) being the most affected. Open wounds were the most common clinical presentation, predominantly involving the dominant hand. Extensor tendon injuries were the most frequent, with the ulnar artery and median nerve being the most commonly injured structures. Road traffic accidents were the leading cause of hand and forearm injuries. Early repairs and mild injuries resulted in better outcomes as assessed by the Quick DASH-9 score, while early mobilization and adherence to strict rehabilitation protocols significantly improved functional recovery. Isolated tendon repairs had better outcomes compared to cases with nerve and bone injuries. Although extensor tendon repairs showed good results, distal volar injuries near the wrist had better overall functional recovery. Abdominal flaps were the most reliable, with hypogastric and groin flaps preferred for dorsal defects and superiorly based flaps for volar defects. Patients undergoing flap procedures had a longer hospital stay.

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