42. The Dreaded Hand Chapter Flashcards
What are key parts of the history to ask for hand exam?
- age
- mechanism
- time occurred
- other injuries
- hand dominance
- occupation
What are key questions to ask for penetrating hand injuries?
Tetanus status
For surgical planning of the hand, what do you need to know?
- NPO status
For nonacute/ nontraumatic/more chronic hand complaints what are 6 key questions to ask pt?
- presence of contracture
- timing of sx
- pain
- palliating/provoking factors
- other extremity same sx?
- functional impairment
Hand physical exam: 4 key categories to assess?
- Inspection
- ROM
- Palpation
- NVS
What are key aspects of the hand exam: inspection phase?
A Skin - wounds, erythema, pallor, cyanosis
B Edema
C Deformity - rotation, angulation, cascade sign
ROM of the hand needs to be assessed both __ and __
passive, active
Palpation of the hand exam: what 4 things are you looking for ?
warmth
joint effusion
tenderness
masses - nodules, ganglions
NVS: what nerve tests flexion of the thumb and index finger (“OK” sign)
median
What nerve tests thumb extension against R?
radial
how to test median nerve - motor?
okay sign
which nerve assesses abduction of fingers against R?
ulnar
how to test radial nerve - motor?
ext thumb against R
How to test ulnar nerve abduction?
finger abduction against R
How to test sensation in the hand exam? Particularly important to test …
two point discrimination
How to test vascular aspect for hand exam (2 helpful test names)
Allen
Cap refill at nail bed
When might a CT scan be indicated in hand injuries?
- complex fractures
- high clinical suspicion of fracture with negative XR
When might an MRI scan be indicated in hand injuries?
ligaments, tendon, soft tissue injuries, particularly:
1. OM
2. Avascular necrosis
3. Bone tumors
Posterior surface of the hand __ surface
dorsal
Palmar surface of hand also referred to as ___ surface
volar
Which hand surface is more prone to swelling?
dorsal
Fingertip is defined as the area distal to DIP. What two muscles attach here?
fdp
extensor tnedons
Distal part of the nail is known as the __ __
nail body
Proximal part of the nail bed is knwon as nail __
root
What is the lunula of the nail?
white, crescent shaped area on nail bed
Represents the distal end of germinal matrix, important for generation of nail plate
Why do we care so much about the lunula?
if damaged, area of germinal matrix so may have perminent damage to nail plate
What tendons and m inserts distal as lunula?
extensor
FDP
Small area of skin covering proximal nail is known as cuticle or __
eponychium
Tge area of skin underlying the distal nail bed is the ___
hyponychium
The skin overlying the lateral portion of the nail bed is known as the __
paronychium
What is important to assess in physical exam of the nail?
cap refill
clubbing
spooning
splinter hemorrhage
discoloration
thickness
What does the flexor retinaculum do at the wrist?
holds the 8 carpal bones bound by ligaments to form carpal tunnel
what passes through the carpal tunnel?
median n
flexor tendons
Boundaries of the carpal tunnel?
volar - flexor retinaculum
medial and lateral - carpal bones
Where are the thumb metacarpal and phalangeal epiphyses? (prox vs distal)
vs
finger metacarpal epiphyses?
proximal
vs
distal
Ossification centres of phalnges and metacarpals appear when?
when do they fuse?
open 10-36mo
fuse by age 14-16y
How does one perform the cascade test?
palm up
gradual increase in flexion from radial to ulnar for joints in hand
*watch for abnormal rotation deformity of digits
DIP flexion (degrees) vs PIP
90 vs 105
What do collateral ligaments at the DIP and PIP joints serve to do?
function laterally both sides for lateral stability and R of lateral, oblique and rotational forces
Fibrocartilaginous plate on anterior surface of IP joint - which side? why?
volar
reinforce joint capsule, limit hyperextension
What does the cascade test tell you? Ie what is normal
fingers come together over thenar and hypothenar eminance, point toward scaphoid
Why are MCP joints less stable than IP?
rounded head metacarpal bone onto concave surface of proximal phalax
good for grasp by allowing some rotational and side-side movement
How does the MCP volar plate differ from IP?
interconnected by deep tranverse ligament
How to test the collateral ligaments of the MCP joint?
in flexion (full)
no ability to abduct or adduct phalanx
differnt than extension where limited s-s mobility is possible
What is the functional position of the hand? **
Wrist: 30 degrees extension
MCP 70-90 degree flexion
PIP and DIP full extension
Metacarpal 3 arches - what are they?
proximal (carpal)
distal (metaracarpal) transverse arch
longitional arch
How to differentiate from the intrinsic and extrinsic m of hands (general)
intrinsic origin and insertion within hand itself
vs extrinsic origin is proximal to hand with tendon insertions inside hand
Thumb: MCP extension and flexion range
ext 10 degrees hyper
70 degree flexion
IP flexion vs extension ability degrees
90 flex
15 hyper
What are the intrinsic muscles of the hand?
- thenar: abd pollicis brevis, flexor pollicis brevis, opponens pollicis
- hypothenar: opponens digiti minimi, flexor digiti minimi, abductor digit minimi
- adductor pollicis
- lumbricals
- interossei
What nerves controls thenar emin (abd pollicis brevis, flexor pollicis brevis, opponens pollicis)?
recurr branch of median n
What nerve adducts and rotates thumb medially (add pollicis)?
ulnar
what nerve innevates hypothenar: opponens digiti minimi, flexor digiti minimi, abductor digit minimi
ulnar
Lumbricals come from which muscle?
FDPLumb
Lumbricals insert at ? hood and base of…
extensor hood
proximal phalanx
Radial vs ulnar lumbricals (nerve innervation)
2-2 radial, ulnar
Dorsal interossei - action and nerve?
4 dorsal
abduct
deep branch ulnar nerve
Extensor tendons pass through dorsum of wrist at __ different compartments, innervated by __ nerve
6
radial
Palmar interossei action, nerve
3 aplmar in intermetacarpal spaces, insert at base 2, 4, 5 proximal phalanx
adduct
deep branch ulnar nerve
Compartment 1 extensors muscles of hand: most radial. What muscles do they contain? Innervation?
abd p longus
ext pollicis brevis
PIN - branch of radial n
Compartment 3 extensors muscles of hand: What muscles do they contain? Innervation?
EPL
radial n
What muscles form the borders of the anatomic snuff box
lateral: abd pl extensor polciis brevis
medial - EPL
Compartment 2 extensors muscles of hand: What muscles do they contain? Innervation?
extensor carpi radiali longus and brevis
insert at base fo second and third metacarpals resp
extend and abd hand at wrist
radial n
Compartment 4 extensors muscles of hand: What muscles do they contain? Innervation?
extensor indicis
etensor digitorum communis tendons
insert extensor hood
ext 4 digits of hand primarily at MCP jt
radial n
What forms the extensor hood/expansion (m)
Lumbrical and interosseous m connect with extensions of ext digitorum tendons to form extensor hood
divides further into 3 bands
what are the three bands of the extensor hood?
2 lateral bands
central tendon/slip
What holds the three bands of the extensor hood together? what does this prevent?
transverse retinacular lig
stops volar displacement of lateral bands
if extensor hood transverse retinacular ligaments become disrupted, what type of deformity will you see?
boutenniere - PIP flexion
Compartment 5 extensors muscles of hand: What muscles do they contain? Innervation?
extensor dig minimi
radial
Compartment 6 extensors muscles of hand: What muscles do they contain? Innervation?
extensor carpi ulnaris
adduct and extend wrist
radial n
Flexor muscles - what two compartments?
ant and post
What muscles are in charge of flexion of the hand at the wrist (3)
FCR
FCU
PL
FCR nerve?
median
FCR in addition of flexion of wrist, also in charge of ?
abduction of hand at wrist
FCU nerve?
ulnar
flexion and adduction of hand at wrist
PL nerve?
median
PL is absent in ?% of pt
25
Both PL and FCU insert at the __ retincaculum
flexor
What 3 m are responsible for flexion of digits and enter the hand via carpal tunnel?
fdp
FDS
FPL
median n (except one branch of fourth and fifth digits of fdp is ulnar)
FDP function
flex fingers at IP (?distal)
FDS functions to flex at __ joints
PIP
Testing FDS integrity - ensure…
flex assoc finger against R at PIP while holding other fingers in extension
Digital flexor sheath of the hand has mebranous and retinacular portion - why do we worry about infection in these moreso than extensor?
avascular - prone to infection
Digital flexor sheath - retinacular component akin to pulley system - overlies __ sheath
synovial
Digital flexor sheath - retinacular component akin to pulley system - made up of ?
palmar aponeurosis pulley
3 cruciform pulleys
5 annular pulleys
*thumb has its own
Digital flexor sheath - retinacular component akin to pulley system - what is the overall function of this system?
maintain tendons in axis with flexion of MPC and ICPs to prevent bowstringing
Digital flexor sheath - retinacular component akin to pulley system - most important pulleys to preserve?
A2 and 4
Path of radial a in hand
through anatomic snuff into deep palmar arch and superficial
deep palamr to anastomose with ulnar
superfiical also does
Ulnar a pathway hand
superficial flexor retinaculum through Guyon canal (pisiform and palmar carpal ligament space)
distal to this it branches into large superifical palmar arch
In the normal anatomy of the flexor pulley system, why are A2 and A4 essential?
narrowest portion of hand
Pulley system (flexor) of hand: A1- ?
C1 - ?
5
3
A1, 2, then C1, and alternates to A5 most distally
Reminder : The median nerve enters the hand via the carpal tunnel. It is respon- sible for sensation of the radial two-thirds of the volar surface of the hand as well as the flexor surface of fingers 1 through 3 and the radial half of the fourth (ring) finger (Fig. 42.15). The motor branch of the median nerve innervates five intrinsic muscles of the hand including the thenar muscles and two of the lumbricals. The extrinsic muscles of the hand innervated by the median nerve include the flexor tendons to the radial three digits and FCR.
Reminder
The ulnar nerve supplies sensation to the ulnar one-third of the hand at both the volar and dorsal surfaces. It is also responsible for sensation of the fifth finger and the ulnar half of the fourth finger. The ulnar nerve is responsible for the extrinsic motor function of the flexor carpi ulnaris (FCU) and the flexor digitorum profundus (FDP) tendons of the fourth and fifth digits. It also innervates the remaining intrinsic muscles of the hand and divides into a volar and dorsal branch at the wrist. The volar branch, along with the ulnar artery, enters the palm through the Guyon canal. It is responsible for movement of muscles of the hypothenar eminence, interosseus muscles, and the lumbricals of the fourth and fifth fingers. The deep branch innervates the adduc- tor pollicis. The ulnar nerve’s motor innervation of the fourth and fifth digits is largely responsible for grip power and injury can significantly alter normal use of the hand.
Reminder: The radial nerve contains superficial and deep branches and pro- vides sensation to the radial two-thirds of the hand on the dorsal sur- face excluding the fingertips. There are no motor function branches for the radial nerve within the hand, though its innervation of the dorsal forearm leads to hand function including extension of the wrist (exten- sor carpi radialis longus) as well as other extensor tendons (extensor digitorum communis, extensor digiti quinti proprius, extensor pollicis longus and brevis).
-
How do you know if sensation is intact? (most sn way)
two point discrim:
Sensation is deemed intact if a patient is able to distinguish between one and two points to a distance of 5 mm.
Rapid mo/sn testing of hand: each n and action?
function of the radial, ulnar, and median nerve is to have the patient make an “OK” sign with their thumb and index finger (testing the median nerve), while dorsiflexing the wrist (radial nerve) and spread- ing/abducting the third, fourth, and fifth fingers (ulnar nerve). For general sensory examination, a clinician can test the finger tufts of the index finger (median nerve), the little finger (ulnar nerve), and the dorsum of the proximal phalanx of the thumb (radial nerve) with two- point discrimination
How to perform a digital block? (general terms)
- skin adequately cleaned - web space each side of digit anesthetized mc
- aspirate to ensure no vessel
- vol 0.5-1ml injected and advanced to volar side phalanx for additional 0.5-1ml
repeat on other side
Advantages of a digital block
- fewer injection sites means less pain for pt
- local = greater edema and distortion which can be avoided with digital block
- less anesthesia is typically needed for regional procedure
Palmar approach of hand/digital block
- needle over metacarpal hed
- subcut, direct then on one side of metaracpal
- advance 1cm aspiration so not in vessel
- give 3cc of local
- withdraw partial and inject other side
If transthecal approach to palmar digital block - if significant R what likely hit? should be little to none in sheath
same idea as palmar apprach just 45 degree angle
if R then tedon, withdraw
Dorsal approach to digital block
- needle at one side dorsal surface approx 1cm prox to mcp joint
adv until palmar aponeurosos/volar edge metacarpal - 2ml here
- while withdrawing, additional 1ml injected along tract
- then repeat on dorsal surface of opp side of same metacarpal
Radial nerve block general recommendations
- volar surface wrist feel a
- lateral to this, after aspiration, give 2-5ml of local
Median n block general recommendations
- tendon FCR felt
- needle over m n which is 1cm ulnar from RCR (between this tendon and PL)
- adv into flexor retinaculum where feel pop (possible paresthesia complaint)
- then withdraw several cm to avoid avoid intraneural injection
In which pt may a median n block be CI?
carpal tunnel (due to BL constriction)
Ulnar n bloc basics at wrist
Needle between ulnar a and FCU tendon
adv ~1cm
Paresthesia? draw back few mm
then inject ~5cc
Pathophysiology of ring causing edema
torniquet - further restriction venous return then eventual arterial
How to first try to remove ring?
- Lubrication of finger and ice/elevation
- distal traction on ring with twisting movement
If there are no signs of neurovascular compromise, deep ring erosion or open wound, what kinds of ring removal attempts can be made
- ring wrap
- rubber band
-two rubber bands under ring and hemostat to pull distal traction - surgical glove - finger of glove over pt effected finger, proximal end of glove under ring
Proximal end of ring then pulled back over ring
followed by distal traction and twisting
When to go straight to a ring cutter, rather than using other methods?
signs of NV compromise, open wound, deep erosion
What should be considered/warned when using ring cutter
gets hot q30s so take breaks
When to use a forearm volar splint?
soft tissue hand/wrist injuries
most wrist, 2nd-5th metacarpal fractures
not for distal radius or ulnar fractures as some pronation is possible
When to use a burkhalter splint? what is this?
metacarpal neck #, MCP dislocation
volar slab 30 deg wrist ext or dorsal slab with 90 deg metacarpal flexion
When to use a forearm sugar tong splint?
distal radius and ulna # as prevents pro-supintation
When to use a thumb spica cast? position? allows…
scaphoid, thumb MCP; de quervain teno
wine glass position immob of 1st mcp, allows thumb dip free to oppose
When to use an ulnar gutter splint?
4-5th metacarpal, mcp joint # prox/middle
when to use a radial gutter splint?
sprains/fractures 2nd-3rd digital metacarpal, mcp jont.
when to use finger splints?
stable middle, distal phalanx #.
For PIP sprains, use ? splint
dynamic - buddy taping
Main 4 types/categories of hand injuries
fracture/bony
tendon
ligament
joint space
What type of fracture pattern are typically stable?
transverse
What hand injury concerns warrant immediate surgical consultation?
- open
- partial/complete amp
- displaced intra articular #
- # not maintaining reduction
What are the 3 mc complications for untreated fractures?
- malunion
- nonunion
- loss of motion
Middle phalanx/PIP injury DDX
head, neck, shaft or base # injury
dorsal/volar/lateral PIP dislocation or sublux
volar plate or collateral lig injury
central slip/extensory injury
fdp/fds injury
DDX for distal phalanx/DIP joint fracture?
tuft, shaft or avulsion #
seymour fracture
crush injury
nailbed injury
subungal hematoma
dip disloc/sublux
mallet finger (dorsal), jersey finger (volar)
collateral lig injury
extensor dig communis injury
FDP tendon injury
Proximal phalanx/MCP joint injury ddx
head, neck, shaft or base #
dorsal, volar or lat MCP dislocation or subluxation
volar plate or collateral ligament injury
trigger finger
clenched fist/fight bite injury
extensor complex injury
fdp or fds injury
Metacarpal/cmc joint injury ddx
head, shaft, neck or base #
crush injury
nail bed or subungal hematoma
mallet thumb
IP joint dislocation or sublux
volar plate or collateral lig injury
extensor pollicis longus injury
Thumb proximal phalamx/mcp joint injury ddx
head, neck, shaft or avulsion #
ulnar collateral lig injury
radial collateral ligament injury
Thumb metacarpal/cmc joint injury ddx
head, neck, shaft #
base - bennet or rolando #
cmc joint dislocation or sublux
oblique cmc lig injury
abd pollicis longuss tendon injury
What is a tuft fracture?
secondary to crush injury of distal phalanx
usually stable
can have lac or subungal hematoma
Transverse vs longitudinal fractures - more stable?
transverse
Fractures of this distal phalanx usually stable/un and __-articular
unstable
intra
Avulsion fracture of the finger base - dorsal injury is known as a ?
Mallet finger - inability to extend distal phalax at DIP
Avulsion fracture of the finger base - volar injury is known as a ?
Jersey finger
inability to flex distal phalanx at the DIP
What is a seymour fracture?
distal phalanx fracture through the physis in peds population
includes SH 1 and 2
Seymour fracture is considered a __ #
open
Tuft fracture management
conservatively with analgesia and splinting: 2-4 weeks protected with finger in splint or molded
Tuft fracture - when to consult a specialist?
displaced and irreducible or open
Do distal phalanx fractures need antibiotics?
no
Transverse fracture of distal phalanx - nondisplaced, management?
protective splinting 2 weeks with reduction first
Longitudinal distal phalanx fracture - management
splinted from middle to distal phalanx, leaving PIP joint mobile
for 3-4 weeks followed by PROM until finger pain free
Mallet finger - management
splinting
neutral pos or slight hyperext continuously for 6 weeks
Mallet finger - when to send to specialist?
fracture of 1/3 or greater articular surface and those who failed conservative tx
Jersey finger - tx if some flexion maintained?
dorsal or volar splint if some DIP flexion is present - only DIP immobilized in 5-10 deg of flexion for at least 6 weeks
Jersey finger - tx if no flexion maintained?
assume ruptured FDP
refer for surgery
meantime immob
Pediatric repair of a Seymour fracture?
irrig
reduction and brace in slight hyperext
nail bed repair - trim proximal nail plate, insert back under eponychial fold with mattress suture (6-0, 7-0 chromic absorbable)
lac repair
closed and well reduced - f/u 7-10d
difficulty or instability of injury after ED - 24h f/u
cephalexin 50mg/kg/day divided into q6h for 7-10d
Middle phalanx fractures - what m inserts along proximal base, thus causing fractures to distal middle phalanx usually result in VOLAR angulation? While proximal fractures usually resuklt in dorsal angulation
FDS
Pilon fracture of the middle phalanx?
complete disruption of articular surface so multiple tendons are involved
unstable in all directions
DDX of middle phalanx #?
volar plate, collateral ligament, central slip, FDP tendon, and FDS tendon injuries when assessing for a possible frac- ture. Associated IP joint dislocations or subluxations should also be considered.
Middle phalanx # - stable, nondisplaced transverse fractures?
dynamic splinting and buddy tape to adj finger
2-3 weeks
rom exercises
What transverse middle phalanx fractures require surgical referral?
angulation
shortening
rotation deformity
In addition to unstable transverse fractures of the middle phalanx, what other fractures need surgical referral?
50% or greater articular surface
or fracture requiring greater than 30 degrees of flexion to maintain reduction almost always unstable
How to cast middle transverse finger fractures that are oblique, spiral, communited?
immobilization with level of wrist - ulnar or radial gutter splint (decreases tendon deforming forces)
Proximal phalanx fractures - ddx injuries
volar plate, collateral ligaments, extensor mechanism, FDP tendon, and FDS tendon. For proximal injuries, the MCP joint should be assessed for evidence of clenched fist (“fight bite”) injuries, trigger finger, and dislocations or subluxations of the MCP joint.
Proximal phalanx fractures - nondisplaced transverse fracture management
dorsal aluminum padded splint extending metacarpal to middle phalanx
mcp in 70-90 of flexion
PIP at 30 degrees flexion
What proximal phalanx fractures need follow up with a hand surgeon within a week?
oblique
spiral
angulated
unstable intra articular
unicondylar or bicondylar # of head of proximal phalanx even if nondisplaced
What is key to evaluate in a metacarpal fracture?
open fracture/fight bite
Where is the most common area of a metacarpal fracture?
neck - weakest
Metacarpal allowable fracture angulation?
Digit II and III
shaft - 10
acceptable neck 10-15
Metacarpal allowable fracture angulation?
digit IV
shaft -20, neck 35
Metacarpal allowable fracture angulation?
Digit V
shaft 20-30
neck 45
Key physical exam test for malrotation of metacarpals?
flexion/cascade sign
Adjacent metacarpal fractures are at risk for what 2 abnormalities?
shortening
instability due to loss of intermetacarpal ligament stabilization
Shortening may occur secondary to multiple metacarpal fractures - why might this cause “pseudoclawing”?
extensor lag secondary to compensatory hyperext at MCP – leads to inadequate extension at PIP
Greater than _mm of shortening in any metacarpal is unacceptable
5
What is a reverse Bennet fracture?
intra articular fractures at base of fifth metacarpal
-normal stabilization by intermetacarpal ligament while tension from ECU causes ulnar and proximal displacement of remainder of base
-hypothenar m displace shaft radially
DDX metacarpal fractures
cmc joint dislocation
clenched fist injury
extensor mechanism injury
FDP/FDS injury
What is helpful tri set of imaging for XRAy hand/metacarpal?
standard ap lat
30 degree pronated lat view for index and middle fingers/supinated for ring and little finger
Metacarpal fractures have a predilection for __ articular #
intra
Pt with stable metacarpal neck fractures - how to manage?
splint in neutral position
f/u 1 week with specialist, likely for 3-4 weeks
Jahass maneuver to manipulate metacarpal neck fractures if outside accetable range - what is this?
MCP and PIP flexed to 90, dorsal/upper pressure applied through proximal phalanx and downward over proximal metacarpal shaft
After reduction - splint in position of safety
Intra articular metacarpal fractures at the base generally require surgical fixation to prevent ___ __
posttraumatic arthritis
Thumb fracture: skier/gamekeeper’s thumb
avulsion fracture at base of proximal phalanx
Where do most fractures of the thumb metacarpal occur?
base
Bennett fracture of the thumb
oblique intraarticular fracture accompanied by dislocation at metacarpal base
Rolando fracture of thumb
communited complete intra-articular fracture at metacarpal base (T or Y shaped) on xray
DDX thumb injuries (other than #)
mallet injury, volar plate injury, collateral ligament injury, IP or CMC joint dislocation or subluxation, extensor pollicis longus tendon injury, or UCL or RCL injury should be considered.
What is a Robert view for xray of thumb?
hyperpronated with dorsum of thumb on radiograph plate for true AP
Recommendations for splinting fractures of thumb
proximal in thumb spica for 4 weeks
if unstable - bennett and rolando to hand specialist
Reduction technique for finger dislocation PIP joint
traction counter traction
hyperextend
flex at PIP
management of joint injuries: if affected joint is dislocated dorsally?
hyperext
management of joint injuries: if affected joint is dislocated volarly?
hyperflexion
Joint dislocation/injury: indications for emergent surgical management?
neurovascular compromise after closed reduction
inability to reduce
contamination of open dislocations for extensive irrigation
Surgical referral of joint injuries for those that are chronic dislocation, or present for > __ weeks
3
MCP joint immobilization after dislocation: ? degrees
vs IP joint
60-70
IP at 30
IP joint typically splinted at 30 degrees- what injury is the exception to this rule?
extension to avoid boutonniere deformity
Dislocations of distal IP joint are rare, but when do happen, often go __
dorsal
Why are dorsal PIP joint dislocations with >1/3 of articular surface considered unstable?
greater detachment of collateral ligament insertion at middle phalanx
Volar dislocation of the DIP may occur with disruption of the __ slip
central
Immobilization of DIP joint dislocations with aluminum padded splint along __ surface of __ phalanx to __ phalanx, with DIP in slight 30 deg
dorsal
middle
distal
Reduction of volar dislocations of the DIP can be challenging given obstruction from ?
lateral band
so probably ask a specialist
Lateral dislocations of the PIP stable after reduction can be treated by…
splint immob at 30 degrees flexion for 2-3 weeks
Simple vs complex dislocations of the MCP - what are considered simple?
Subluxations
yet exam may show joint locked in greater than 60 deg of hyperext
Simple vs complex dislocations of the MCP - what are considered complex?
when metacarpal head ruptures through volar plate, then entrapped within joint space
*dimpling at skin in proximal palmar crease is classic
Collateral ligament MCP injury: splklint in ..
neutral for 3 weeks
Simple vs complex dislocation of MCP - management
simple - closed reduction, position of safety
complex - surgery
What type of dislocation of the CMC joint is most common?
posterior
Thorough __ testing is required for fifth CMC joint dislocations
ulnar
3 common radigraphs of the hand
PA
lat
oblique
Management of a CMC joint dislocation
reduction
hand specialist referral in 24 hours
Which collateral ligament of the thumb is more likely to be disrupted?
ulnar
How does ulnar collateral ligament injury occur?
usually secondary to sudden radial deviation of thumb while abducted
What is a Stener lesion?
round palpable mass rarely noted along ulnar side of metacarpal neck with complete tear of UCL
How to test for CMC collateral laxity?
The examiner should sta- bilize the metacarpal with one hand and passively stress the proximal phalanx in the radial and ulnar direction with the other hand. If there is significant laxity at the MCP with radial deviation, assume there is a tear to the UCL. Likewise, if there is laxity with ulnar deviation, assume there is a tear to the RCL.
Greater than _ degrees of laxity at CMC compared to opp thumb at MCP joint indicates complete disruption of associated collateral ligament
30
CMC joint: The IP joint should be immobilized in 30 degrees of flexion for _ weeks. Irreducible dislocations and open dislocations require surgical management.
3
For collateral ligament injuries, most stable grade I and II inju- ries (less than 30 degrees of laxity) may be managed conservatively with immobilization of the MCP joint via thumb spica splinting for 4 weeks.
How does this differ for grade iii/complete tears?
immob in thumb spica splint
What makes up the extensor mechanism in the hand?
EDC digits II-V connecs with lateral bands to form central slip
Where does the central slip insert?
base of middle phalanx and functions to extend phalanx at PIP
Where do the lateral bands from extensor mechanism come from?
intrinsic m - lumbricals and interossei
Extensor mechanism has 9 zones. Even numbered are those over… while odd are over…
bones
joints
Joints of extensor mechanism TI-V
I - IP joint
II - proximal phalanx
III - MCP joint
IV - metacarpal
V - carpus
Important for extensor mechanism to palpate…
tenderness
laxity
step off
with palm down on stable
MC extensor tendon injury is … in which zone?
mallet
zone 1
Zone 1 extensor tendons: what are they?
distal phalanx and DIP
mallet finger from FDP
extensor lag common
Zone 2 extensor tendon: what anatomy is included in this?
middle phalanx injury, usually lac
rare to form from tendon’s central and lateral bands here
Zone III extensor tendons: what injuries are in this area?
PIP
central slip
ex boutenniere
Boutonniere deformity definition
hyperflex at PIP
and hyperext at dip/mcp
Boutonniere deformity occurs with __ __ disruption
central
Integrity of central slip is based on Elson test - what is this?
PIP in max flexion
hold R against extension of middle phalnx
If slip is disrupted - increase in tone at DIP and ext/hyperext of PIP
vs N is no extension of DIP due to distal slack at lateral bands
Zone IV extensor concerns:
mainly lacsZo
Zone V injuries: what does this typically entail?
sagittal band at MCP joint
- mc radial sagitttal band of finger due to forced flexion/direct blunt force
Sagittal band injury: what is this?
common mechanism is forced flexion or direct blunt force. Swelling and tenderness over the dorsal MCP joint will generally be appreciated on exam. The patient can usually keep the joint in extension, though with active extension from the finger in flexion, there is a snapping relocation of the extensor mechanism.
Sagittal band injury: classification system type I- III
I - no tendon instability
II - tendon sublux/snap
III - complete disruption
Zone VI - typical injury in extensor mech?
lacs
Zone VII extenson tendon injuries - what is common here?
lacs over carpals and extensor retinaculum
Work up for a tendon injury
xray
Closed extensor injuries are treated acutely with ___
immob
Grossly contaminated open lacs, including crush injuries and large open wounds should be managed by ..
emergent f/u with hand specialist
irrig and tetanus, IV prophylactic abx such as cefazolin 1g q87h or vanco if allergic
Open lacerations of extensor tendons: discharged with what abx?
cephalexin 500mg q8h 7-10d or pen allergic = doxy 100mg mg PO BID x7-10d
Zone 1 extensor injury management: mallet finger splinting:
DIP immob in full ext/hyper - 6-8 weeks then nightime splint
f/u hand specialist within week
Zone II extensor injury: lac?
simple closure, splint dip in extension for 2 weeks
Zone 3 extensor injury management: boutonneire injury treated by splinting..
PIP in ext 4-6 weeks with DIP flexion exercises
Zone IV extensor injury management: splint?
yes - like zone III, pip in extension with dip free to move
Zone V extensor injury: stable sagittal band injury (type I): treated with ?
buddy/dynamic tape
loss of extension needs tendon repair
Zone V extensor injury: type II injury with sublux - treatment?
mcp flexion blocking splint (MCP joint extension with PIP and DIP joints free)
Zone V extensor injury: sagittal band type III injury with complete disruption - stabilized with MCP flexion blocking splint AND
refer to hand specailist
Zone VI extensor injury management:
recommend discuss with hand specialist as an emerg doc can do but… ye know.
hand and wrist immob with volar splint - position of safety
Basics of an extensor tendon injury: when to see a hand specialist
probably within next week
Flexor tendon injuries: majority open injuries are secondary to …
deep lac
What is the mechanism of closed flexor tendon injuries?
forced hyperextension that is in active flexion
FDP and FDS mc
mc fourth finger and FDP
Hx of FDS flexor tendon injury?
pop or tear with pain over flexor surface
bow stringing on exam when multiple pulleys injured, usually A2, A4
3 main types of FDP avulsion injury : type I:
complete avulsed tendon
migrates proximally through tflexor sheath into palm
risk of comrpomised vasculature
see surgeon asap!!
3 main types of FDP avulsion injury : type II:
complete avulsion with proximal retraction to level of PIP
risk vascular supply, see surgeon asap
3 main types of FDP avulsion injury : type III:
avulsed tendon only to level of A4 pulley
less vascular supply concern - still see surgeon asap
Flexor tendons divided into 5 anatomic zones: zone 1 location?
insertion of FDP at distal phalanx to just distal to insertion point of FDS
Flexor tendons divided into 5 anatomic zones: zone II location?
distal palmar creaes to proximal portion of middle phalanx
includes fdp and fds
Flexor tendons divided into 5 anatomic zones: zone III location?
immediately distal to carpal tunnel to proximal proximal flexor sheath of digits
Flexor tendons divided into 5 anatomic zones: zone IV location?
includes carpal tunnel
*median n
Flexor tendons divided into 5 anatomic zones: zone V location?
proximal to carpal tunnel
usually deep, concern for mult tendons
Are avulsion fractures common with flexor tendon injuries?
yes
Should patients with both open and closed flexor tendon injuries see a hand specialist?
yes
Emergency hand consultation for flexor tendon injury when?
- open
- dislocation
- grossly contaminated
- bites
- arterial injury
- if wound in ED cannot be closed overlying tendon
How to immobilize a flexor tendon injury?
- blocking splint to prevent further retraction of flexor tendons with MCP 70-90 of flexion
IP joint minimally flexed 10-15 deg
Open wound flexor tendon abx recommendations?
cephalexin 500mg PO TID 7-10d or boxy 7-10d (100mg po bid)
What is the definition of a primary repair for flexor tendon injury?
end to end within 24 hours
should be repaired within 3d for flexor tendon injuries
If have to delay seeing hand specialist (delayed primary closure), how to treat/prep hand?
irrigate
close with loose sutures
splinted in functional pos
What are common complications of flexor tendon injuries?
adhesions
infection
tendon contracture
What is a rare complication of flexor tendon repair and when does it often occur?
recurrent rupture
5 weeks post
abn cascade sign, don’t do any flexion activities - refer back within 3d
Trigger finger - what is this?
overuse injury from repetitive movements in flexion that leads to inflammation and narrowing at the A1 pulley so stops smooth tendon movement
Common complaints/hx when diagnosing trigger finger?
catching and pain flex/ext
What diseases put people at risk for developing trigger finger?
inflammatory joint disease
DM
hypothyroid
Management of trigger finger:
NSAID
splint with MCP blocking splint at slight flexion 10-15 deg for 6-10 wekes
If pt fail conservative management for trigger finger - what kind of surgery is performed?
A1 pulley release
You can do a CS injection for trigger finger - what are the two methods?
intra and extra sheath
u/s volar: intra sheath at 45 degrees in LA approach, needle advanced until tip between FDS and FDP only 0.5ml of steroid triamcinlolone acetonide 10mg/ml and anesthetic injected
extra: need rests at distal end A1 pulley superficial to FDS and FDP
How is a subungal hematoma or bleeding under nail bed described?
percent nail bed covered with blood
DDX of a nailbed injury
underlying tuft
open fracture
subungal hematoma
mallet finger
fdp tendon injury
Image in a nail bed injury?
yes! fracture - may need surgical reapir
What kind of nail bed fracturs need surgical repair?
transverse fractures of distal phalanx and intra articular fractures
comminuted are often stable!
When does a subungal hematoma need trephination (opening nail bed to release blood)
greater than 50% nail bed
How to trephinate a nail?
hole to provide drainage of hematoma with sterile 18g needle
When does surgical repair of the nail need to be done? damage to nail __ or __
bed
root
How to do a nail bed repair
- anesthetize area with lido/digital block
- 6-0 absorbable suture to directly repair lack
- recommendation at this time is to reposition nail after repair of nail bed
-typically done by stabilization of nail under eponychial fold so soft tissue can stabilize
Recommended abx for nail bed injury?
then f/u with..
cephalexin/first gen cephalosporin IV first dose then 10d of oral cpehalosporin
f/u hand specialist
Zone I finger amputation:
distal to bony phalanx
Zone II finger amputation:
area between distal phalanx and lunula
Zone III finger amputation:
proximal to lunula
Zone I and II amputation injury functionality vs III
pretty good just short
III - concern for FDP with flexion and stiffness and both PIP and DIP
If children less than 3-4 years old have distal tip amp, tissue can be reattadched with ?
composite graft if 1cm in size r less
but really just talk to a hand specialist
Indications for reimplantation of finger amp?
- amputation of thumb
- mult adj digits
- ped pt
- clean, sharp amps
Relative contraindications to reimplantation attempts of digits:
- severe crush or contaminated
- significant comorbidities
- multilevel amp of save digit
Management of a finger amp:
1.ABC
2. assessment of wound - amp tissue in NS soaked cause, clean bag and ice water for viability over next few hours
3. control bleed
4. irrigate injury without further disruption
5. radiograph
6. hand specialist
Options for amputated pt if reimplant is not an option?
free graft
cross flap
advancedment of flaps
skin graft
healing by secondary intention
In patients with small tuft avulsions <1cm, loss of soft tissue with nail intact and covering bone, heal by..
secondary intention after thorough irrigation and debride of nonviable tissue
then loose approx of tissue allows
ABx for amputation injury?
cephalexin 500mg TID or oral doxy 100mgpo bid x7d if gross contamination
BUT NOT NECESSARY if clean wound and immunocompetent pt
For finger amps, immediately contact hand specialist unless injury is ..
zone 1
After amputations of finger, what is mc residual subjective sx?
cold intolerance at tip
What is the defn of a ring avulsion or regloving injury?
tissue pulled off and can involve varying degrees of tissue
Urbaniak Classification for Ring Avulsion Injuries - Class I
circulation adequate
Urbaniak Classification for Ring Avulsion Injuries - class II
circulation inadequate
Urbaniak Classification for Ring Avulsion Injuries - class III
complete degloving injury or complete amp
Most hand or finger lacs can be closed with which sutures?
simple interrupted
4-0 or 5-0 nylon/nonabsorbable suture to evert wound edges
use absorbable vicryl 4-0 or 5-0 for deep layers
When can you use tissue adhesive to close wounds?
bleeding controlled in areas lacking tension
no underlying structures exposed to adhesive
Lacs of the joint capsule - chat with who?
hand specialist
How to complete a basic extensor tendon repair?
talk to hand specialist
nonabsorbable 4-0 in finger, 3-0 in hand
figure of 8 or mattress stitch
If there is any concern for a lac infection, what abx?
keflex 500mg PO BID or doxy of allergic 100mg po bid x7 days
Clenched fist injury: what do you worry about?
risk of intrustion into joint, tendon sheath or bone
Clenched fist injury: bugs to worry about and what abx to tx with inpt vs outpt
staph
strep viridans
eikenella corrodens
inpt: amp/sublactam 3g IV q6h
out: amox clav 875 BID or clinda 600 q8h x7d if allergic to pen
Clenched fist injury needs __
irrigation!!
Paronychia: what is this?
acute inflamm or infectious change in skin or under one nail fold lining nail bed
often due to trauma/FB
Paronychia: if abscess, tx?
I+D
plus removal any FB
don’t damage nail bed - nail fold elevation by blunt dissection or scalpel to release purulent fluid
Paronychia: if no abscess, tx?
digit in 1% acetic acid and warm water 15 mins 2-4x/day to decrease pseudomonas and others
+ topical mupirocin 7-10d
Onychomycosis: what is this?
mycotic infection within nail rather than nail folds
tx antifungal: oral fluconazole 150-450mg weekly but maybe f/u pcp cause can be chronic
Onychomycosis: classic finding
thickening of nail itself/hyperkeratosis from invasion of fungi
What is a nail felon?
infection of pulp space of finger tip, usually by penetrating trauma like DB needle
Felon - why does this have severe pain?
fibrous eptae of finger create small compartment which restricts sweling and leads to incr in pressure, n and vascular compromise and then necrosis of tissue
Felon - increased risk of what two diseases?
OM
tenosynovitis
Tx felon
keflex 500mg po tid x7d and warm soaks
if abscess, I and D
Herpetic whitlow: what is this?
cutaneous HSV on fingers from contact of oral
DX of herpetic whitlow:
viral culture of PCR of unroofed lesion
Tx herpetic whitlow in an uncompromised pt vs compromised?
none
oral acyclovir 800mg Po BID or valacyclovir 500mg BID x7 days
Purulent flexor tenosynovitis: mc sx
fusiform swelling of digit, direct tenderness over flexor sheath
Most sp sign of Purulent flexor tenosynovitis
passive extension pain
Purulent flexor tenosynovitis: which lab test maybe be helpful
ESR
Purulent flexor tenosynovitis: management
vanco 10-15mg/kg IV
surgical wash out is definitive
Kanavel signs of Purulent flexor tenosynovitis: 4
- exquisitie tenderness specifically over sheath
- flexion of finger
- exquisite pain extending finger, particularly at proximal end
- whole involved finger is swollen (ie fusiform swelling)
Onycholysis: what is this?
separation nail from nail plate at distal end to start and continues more proximally
cause: trauma, infection, systemic disease too like thyroid, psoriasis, certain chemos
What is a high pressure injury?
finger accidentally on nozzle of someething when being cleaned
as comes from small pin - damage often underestimated
caustic chem injectio and tissue destruction leads to swelling and ischemia
IE CAUSES COMPARTMENT SYNDROME
High pressure injection tx:
- IV abx keflex or ceftr
- pain control
surgical decompress and wash out
Ganglion cyst: are they related to trauma?
no
Ganglion cyst: tx
aspiration often repeats
CS recur
surgical probably best with low recurrence rate
blunt force does sometimes work
Ganglion cyst: typical form how?
mobile firm cysts filled with mucin
Dupuytren’s Contacture: what is this?
fibrosis of palmar fascia
causes tightening of an area of fascia creating cord limiting motion of specifc finger/palm area
Duputren’s contracture: management?
hand specialist
. Which of the following demonstrates the motor function of the median nerve?
a. Extending the hand at the wrist
b. Making an “OK” sign with the thumb and first finger
c. Pulling the thumb across the palm to touch the little finger
d. Spreading out the fingers of the hand
b
- A 25-year old woman comes to the emergency department com-
plaining of hitting the tip of her finger on a basketball. She has difficulty extending the tip of her ring finger. What is the most appropriate splinting technique for this injury?
a. Aluminium volar splint with finger in position of function
b. Dorsal blocking splint with DIP at 15 degrees of flexion c. Stack splint with extension of distal phalanx
d. Ulnar gutter splint to include ring finger to the tip
c - mallet
After cutting her hand while washing a drinking glass, a patient complains of a laceration to her finger. In which location of the pal- mar hand surface is this laceration most likely to cause a lack of flexion to the index finger PIP joint?
a. Base of the thenar eminence
b. Distal end of the middle phalanx
c. Proximal end of the proximal phalanx
d. Volar crease of the MCP joint
d - fds
- Which of the following is the most disease-distinguishing finding of
a patient with pyogenic flexor tenosynovitis? a. Involved finger is held in flexion
b. Pain on extension of the finger
c. Tenderness over the tendon sheath
d. Uniform swelling of the involved finger
b
- A patient presents after a fist fight with a puncture wound to his
hand. Which description of the presentation has the best prognosis? a. Fingertippenetration
b. Delay in treatment
c. Depth of the wound
d. Involvement of joint
a
What three factors worsen px of fight bite?
delay in tx and ID
further depth
intrustion into joint
