43. Hand

Question 1

10 limb threatening conditions that require immediate intervention and hand consult

Answer 1

1. Compartment syndrome
2. Crush
3. High pressure injection
4. Open #
5. Amputation
6. Vascular injury
7. Serious infection
8. Burns - esp circumferential
9. Dislocations
10. Complex #s

Question 2

4 intrinsic muscle groups

Answer 2

 thenar
 hypothenar
 interosseus
 lumbrical

Question 3

2 main arteries of blood supply

Answer 3

radial and ulnar

Question 4

Test of radial nerve

Answer 4

motor: test with wrist extension, thumb or digit extension
Sense: webspace

Question 5

test of ulnar nerve

Answer 5

motor: finger abduction
Sense: baby finger pad

Question 6

Test of median nerve

Answer 6

motor: okay sign
Sense: index finger pad

Question 7

When to xray subungal hematoma

Answer 7

If fingertip unstable

Question 8

When to give ABx for subungal hematoma

Answer 8

If grossly contaminated and distal #

Question 9

Exceptions to removing FB in hand in ED

Answer 9

<3mm and inert material

Close to vessel or nerve

Question 10

9 indications to have OR removal of FB

Answer 10

1. large or multiple FB
2. Tendon or NV injury
3. Penetration of deep space
4. Joint penetration
5. # or bone penetration
6. Very comtaminated
7. Immune compromosed
8. Lead FB
9. Liquid FB

Question 11

MGMT of distal phalanx #

Answer 11

• non-displaced should be splinted in extension for 2-3 weeks
• if angled, rotated, displaced, may need reduction then volar splint
• avulsions should be splinted to reduce tension of fracture and send to hand surgeon

Question 12

What is mallet finger

Answer 12

o extensor avulsion

o inability to extend DIP

Question 13

MGMT of mallet finger

Answer 13

Splint in full extension

Question 14

MGMT of middle or proximal phalanx

Answer 14

1. If non-displaced can buddy tape for early protected motion
2. If unstable or displaced need to reduce
   - If reduced place in gutter or AP splint
3. If spiral or comminuted, should get hand surgery

Question 15

MGMT of thumb metacarpal #

Answer 15

> 30 degrees angle should be reduced and immobilized in abduction

Question 16

What are a Bennet and Rolando thumb #

Answer 16

Bennet - Piece off - thumb spica

Rolando - Comminuted - hand surgeon

Question 17

Sprain grading system

Answer 17

o1. Stretch with small tears
o2. Incomplete partial tears
o3. complete

Question 18

MGMT for non-displaced MCP #

Answer 18

splint in wrist extension and MCP at 90 degrees

Question 19

MGMT of base of metacarpal #

Answer 19

hand surgery

Question 20

goal of MCP reduction

Answer 20

<3mm shortening, <10% angle, no rotation

Question 21

MGMT of MCP neck #

Answer 21

<15% angulation ,and up to 35% for ring and baby

90-90 method with intrinsic splinting

Question 22

MGMT of PIP dislocation

Answer 22

o reduction using longitudinal traction and hyperextension
o >1/3 of joint space need OR
o dorsal and lateral dislocation should be in 20-30 degree flexion block splint
o volars should be reduced and placed in full extension

Question 23

MGMT of thumb IP dislocation

Answer 23

splint in functional position x 3 weeks

Question 24

MGMT of MCP dislocation

Answer 24

o reduce with wrist in flexion and direct dorsal pressure

o splint in 90 deg MCP flexion

Question 25

MGMT of thumb MCP dislocation

Answer 25

o radial or median nerve blocks

o reduce with flexion of wrist and thumb adduction, then dorsal pressure

Question 26

MGMT of Carpometacarpal (CMC) dislocation

Answer 26

o closed reduction with wrist flexion and traction
o splint in neutral position
o may be unstable and need OR

Question 27

MGMT of UCL injury (gamekeeper thumb)

Answer 27

o thumb spica and OP hand surgery referral

Question 28

Timeline to repair extensor ligament

Answer 28

2 weeks

Question 29

Extensor tendon zones and their MGMT

Answer 29

o	Zone I
	May have lag or reduced strength
	Mallet finger most common
	Closed
•	Early immobilization in extension
	Open
•	Closed with 5-0 non absorbable and splint in extension
o	Zone 2
	Tx same as for zone 1
o	Zone 3
	May get bourtonierre from damage to dorsal hood
	Should suspect if dorsal swelling and PIP flexion
	Closed
•	Immobilize in extension
	Open
•	Immediate surgery consult and IV ABx
o	Zone 4
	Do not retract
	Can repair with 5-0 non-absorbable
	Immobilize in functional position
o	Zone 5
	Xray to RO # 
	Inability to extend MCP joint
	Assume from tooth if no good story otherwise
•	Tx with clavulin if so
	Washout if involves the joint
o	Zone 6
	Splint with wrist and MCP in functional position
	Refer to hand specialist
o	Zone 7-8
	Hand surgeon

Question 30

MGMT of flexor injuries

Answer 30

o Decontaminate, tetanus and ABx
o Hand surgery for all flexor injuries
o Close open wounds
o Immobilize in 30 degree wrist flexion and MCP in 70 flexion

Question 31

6 Indications to reimplant digit

Answer 31

1. multiple digits
2. Thumb
3. Wrist and forearm
4. Sharp amputation with minimal avulsions
5. Single digit between PIP and DIP
6. All peds

Question 32

4 contraindications to reimplant digit

Answer 32

1. Unstable patient with life threatening injuries
2. Multi-levels
3. Self inflicted
4. Single digit proximal to FDS insertion

Question 33

MGMT of amputation

Answer 33

o	Control bleed
o	Clean gross contaminants
o	Place part in saline gauze in bag on ice
o	Cover stump and elevate
o	ABX and tetanus

Question 34

3 zones of fingertip avulsion

Answer 34

zone 1 involves no bone
zone 2 bone is exposed and nail bed
zone 3 has entire nail bed missing

Question 35

MGMT of paronychia

Answer 35

o if no abscess, oral ABx and soaking daily
o if abscess, need to lift cuticle to drain
o no ABx unless cellulitis

Question 36

Define tenosynovitis

Answer 36

• synovial space infection of the flexor tendon and associated bursae
• 1 and 5th digit can communicate with each other and cause horseshoe infection

Question 37

MGMT of tenosynovitis

Answer 37

o Hospital admit
o IV aBx
o OR consult