APPROACH TO HAND INJURIES Flashcards
HPI
Location
Age (of wound)
Mechanism: shear, blunt, crush
Contamination
Foreign Body Sensation
Foreign Body Type
Associated Symptoms
r/o
Life threatening Injuries
Limb Threatening Injuries
Neurovascular compromise
Loss of function
PMHx: Risk Assessment
Extreme of Age
Hand dominance
Diabetes
Chr Renal Failure
Obesity
Malnutrition
Immunosuppression
Allergies
Latex
Anesthetic
Immunization
Tetanus Status
Social Hx
Occupation
Elements of physical exam
Inspection
Palpation
Motor testing
Sensory Testing
Tendon Assessment
Vascular Assessment
Compartment Syndrome Testing
Elements of the motor test
make a fist
straighten fingers
radial, ulnar, median nerve testing
Motor testing of the radial nerve
Dorsiflexion of the wrist
Thumbs up sign
Motor testing median nerve
Thumb interphalangeal joint flexion “Okay sign”
Motor Testing ulnar nerve
Abduction / Adduction of digits
Sensory assessment distal to the mid palm
Static 2 point discrimination
Normal < 6 mm apart
Inspect for loss of sweating ability and papillary ridges
Ten Test - rate affected area compared to unaffected area, rate on scale of 10
Test in radial, ulnar, median distributions
Sensory testing radial nerve
First dorsal web space
Sensory testing Median nerve
Volar tip of index finger
Sensory testing ulnar nerve
Volar tip of little finger
Tendon assessment
Extensor digitorum
Flexor digitorum profundus
Flexor digitorum superficialis
How to test Flexor digitorum superficialis
Hold all other digits in extension
Flex the proximal interphalangeal joint AGAINST RESISTANCE
How to test Flexor digitorum profundus
Hold proximal IP joint against resistance
Flex the distal interphalangeal joint AGAINST RESISTANCE
How to test Extensor digitorum
Sequentially flex the MCP, PIP and DIP
Have patient extend the digit against gravity and AGAINT RESISTANCE
Signs of partial tendon involvement
Weak, limited or painful movement
Best Vascular Assessment
Allen’s Test
Allen’s Test suspicious for significant vascular injury
Refill time > 3 seconds
XRAY views
AP
Oblique
Lateral
XRAY Indications
Bony injuries
Foreign Bodies
Joint penetration
Indications for prophylactic antibiotics
Complicated hand lacerations
Mammalian bite wounds
Injuries > 12 hrs old
Contaminated wounds
Exposed bone
Concurrent medical problems affecting wound healing (DM, Renal disease, peripheral vascular disease, immunocompromise)
Definition of complicated hand laceration
Human or animal bite
Burn
Fracture through bone or joint
Tendons, bones, large vessels or nerves
Severe tissue damage or maceration
List the Special Tests
Snuffbox Tenderness
Grind Test
Finkelstein’s Test
Tinel’s Sign
Phalen’s Maneuver
Durkan’s Compression Test
Snuffbox Tenderness
Tenderness with deep palpation between tendons of EPL and EPB just distal to the radial styloid
Scaphoid fracture
Grind Test
Axial compression and rotation of the MCP joing of thumb
Degenerative arthritis
Finkelstein’s Test
Grasp thumb and deviate ulnarly
Tenosynovitis of the EPB and ABL (de Quervain’s disease)
Tinel’s Sign
Paresthesias after tapping over the course of the median nerve
Carpal Tunel Syndrome
Phalen’s Maneuver
Flexion of the bilateral wrists for 1 minute. Paresthesias in the hand.
Carpal Tunel Syndrome.
Durkan’s Compression Test
Direct median nerve compression at transverse carpal
ligament. Paresthesias.
Carpal Tunel.
Flexor Pollicis Longus (FPL) Test
Bend tip of the thumb
Flexor Digitorum Profundus (FDP) Test
Stabilize the PIP joint, isolate the DIP
Flex tip of the finger
Flexor Digitorum Superficialis (FDS) Test
Isolate Affected Digit
Block other digits
Flex the PIP
Abductor pollicis longus (APL) and extensor pollicis
brevis (EPB) Test
Abduct thumb out to the radial side
The examiner palpates the taut tendons over
the radial side of the wrist
Extensor carpi radialis longus (ECRL) and
extensor carpi radialis brevis (ECRB)
Make a fist, Extend wrist back
The examiner then palpates the tendons over
dorsoradial aspect of wrist
Extensor pollicis longus (EPL) Test
Placing hand flat on the table
Lift only the thumb off the table
Extensor digitorum communis (EDC) test
Straighten fingers
Extensor carpi ulnaris (ECU) test
instructing patient, “Pull your hand up and out to the side”
examiner palpates the tendon over the ulnar side of the wrist.
Adductor pollicis (AdP) test
forcibly grasp a piece
of paper between the thumb and radial
side of the index P1
Froment’s sign = compensatory flexion at the IP joint
Interosseous muscles test
applying resistance to the index and
small finger and instructing patient,
“Spread your fingers apart”
Best sign of healing
No pain
