Chapter 44: Surgery of the Hand and Wrist
For vascular injuries to the hand requiring tourniquet, the maximum time the tourniquet should be applied to prevent tissue necrosis is
Initial treatment for an actively bleeding wound should be direct local pressure for not less than 10 continuous minutes. If this is unsuccessful, an upper extremity tourniquet inflated to 100 mm Hg above the systolic pressure should be used. One should keep this tourniquet time to less than 2 hours to avoid tissue necrosis. Once bleeding is controlled well enough to evaluate the wound, it may be cautiously explored to evaluate for bleeding points. One must be very cautious if attempting to ligate these to ensure that adjacent structures, such as nerves, are not included in the ligature. (See Schwartz 10th ed., p. 1799.)
Anesthetic agents with epinephrine should NOT be used in
A commonly held axiom is that epinephrine is unacceptable to be used in the hand. Several recent large series have dispelled this myth. Epinephrine should not be used in the fingertip and not in concentrations higher than 1:100,000 (ie, what is present in commercially available local anesthetic with epinephrine). Beyond that, its use is acceptable and may be useful in an emergency room (ER) where tourniquet control may not be available. Also, because most ER procedures are done under pure local anesthesia, many patients will not tolerate the discomfort of the tourniquet beyond 30 minutes. Epinephrine will provide hemostasis and also prolong the effect of the local anesthetic. (See Schwartz 10th ed., p. 1796.)
Most nondisplaced fractures do NOT require surgical treatment EXCEPT
A. Those of the lunate bone of the wrist.
B. Those of the capitate bone of the wrist.
C. Those of the scaphoid bone of the wrist.
D. All nondisplaced fractures require surgical treatment.
Most nondisplaced fractures do not require surgical treatment. The scaphoid bone of the wrist is a notable exception to this rule. Due to peculiarities in its vascular supply, particularly vulnerable at its proximal end, nondisplaced ...