How to manage a deep hand laceration (cut) with tendon and nerve injury in a middle-aged lady?

Management of Deep Hand Laceration with Tendon and Nerve Injury

Primary repair is the recommended management for a deep hand laceration with tendon and nerve injury, as lacerated tendons and nerves cannot heal without surgical approximation.

Assessment and Initial Management

When evaluating a patient with a deep hand laceration involving tendons and nerves:

1. Initial wound care:

   • Clean the wound thoroughly with irrigation to remove foreign bodies and pathogens
   • Avoid high-pressure irrigation as it may spread bacteria into deeper tissue layers 1
   • Apply sterile dressing

2. Neurovascular assessment:

   • Evaluate sensory function in the affected digits
   • Assess motor function of the hand
   • Check capillary refill and perfusion of digits

3. Splinting:

   • Apply a temporary splint to immobilize the hand in a functional position
   • This prevents further damage to injured structures before definitive repair

Definitive Management

Primary Repair (Option A)

Primary repair is the correct management approach because:

• Lacerated tendons and nerves cannot heal without surgical approximation 2
• Early repair leads to better functional outcomes and quality of life
• Delayed repair can lead to tendon retraction, making subsequent repair more difficult
• Nerve injuries benefit from early repair to maximize potential for recovery

The surgical procedure involves:

• Adequate anesthesia (regional or general) 1
• Proper visualization and exposure of the wound
• Identification and repair of all injured structures:
  1. Nerve repair
  2. Tendon repair
  3. Repair of any vascular injuries if present

Why Other Options Are Not Appropriate

• Debridement with primary closure (Option B): Insufficient for tendon and nerve injuries as it does not address the functional repair of these structures
• Debridement with secondary closure (Option C): Delays definitive treatment and may lead to worse functional outcomes
• Vacuum assisted closure (Option D): Not appropriate for primary management of tendon and nerve injuries; may be used as an adjunct in complex wounds but not as the primary treatment

Postoperative Care

After primary repair:

1. Immobilization:

   • Hand should be immobilized in a functional position for appropriate duration
   • Specific duration depends on the structures repaired

2. Antibiotic therapy:

   • Consider short-course antibiotics (3-5 days) for deep wounds 1

3. Rehabilitation:

   • Early referral to hand therapy
   • Controlled mobilization protocols to prevent adhesions while protecting the repair

Potential Complications

• Tendon adhesions limiting range of motion
• Incomplete nerve recovery
• Infection
• Complex regional pain syndrome
• Stiffness

Special Considerations

• Kitchen injuries often involve sharp objects that create clean lacerations, which are favorable for primary repair
• The patient's occupation and hand dominance should be considered when planning rehabilitation
• Patient education regarding the expected recovery timeline and potential functional limitations is essential

Primary repair provides the best chance for optimal functional recovery, reduced morbidity, and improved quality of life for patients with deep hand lacerations involving tendons and nerves.