Disorders of the Hand Flashcards
Zones of the Hand in Relation to Injuries (zones 1-6)
Zone 1: an injury AT or DISTAL to the DIP or (IP for thumb)
Zone 2: injury at P2 (second phalynx bone (between DIP and PIP) or the proximal pahlynx of the thumb
Zone 3: injury at the PIP (middle joint) or the MCP (metacarpal phalnygeal joint) on thumb
Zone 4: injury at the P3 (proximal phalynx) or the metacarpal of the thumb
Zone 5: injury of the MCP (metacarpal phalngeal joint) knuckles or the CMC (metacarpal to wrist joint bone) of thumb
ZOne 6: anywhere over the hand (not fingers)
Extensor Tendon Rupture of the hand
Open v Closed Injuries
Extensors of the hand: on the dorsal (backside) of the hand
Open Inuries
- avulsions
- sharp injuries
- lacerations
Closed
- RA, gout and previous hardware weaken the tendons
- sports or occupation
Diagnosis
- clinical
- imaging for suspected fractures
Treatment
Conservative
- if Zones 1 and 3, or partial lacerations, etc.
- splinting 6 weeks then nighttime + OT
Surgical Repair
- for those open and those involving greater than 50% of the tendon structures
- for those with assocaited soft tissue damange
- NV compromise and contaimination
Mallet Finger
Etiology
Symptoms
Signs
Etiology
- a Zone 1 injury
- sport, jamming finger or work
- comonly an avulsion injury of the extensor tendon due to (finger jam in door!)
Symptoms
- painfull and swelling at the DIP joint
- inability to fully extend the DIP (sit with it slightly bent)
Signs
- fingertip resting at 45 degrees
- lack of ability to extend
Diagnosis: Xray can see avulsion fracture
Treatment
Non-Operative
- extensor splinting of the DIP 6-8 weeks 24hrs.
Operative
- CRPP or ORIF
- risk of swan neck deformity
Boutonniere Deformity
etiology
symtpoms
Etiology
- a Zone 3 injury: at the PIP of the extensor tendons
- laceration
- jammed finger
- RA
Symptoms
- a DIP extension with PIP flexion
- Elson’s Test : bend PIP 90 degrees over a table & extend middle phalnyx under resistance = + would be weakness at PIP extension and rigid DIP
Treatment
NOn-Operative
- extension splinting of PIP x 6 weeks with nighttime splinitng
Operative
- central band repair
- lateral band reconstruction or tendon reconstruction
Flexor Tendon injuries
types
exam & workup
Treatment
flexor tendon injuries: flexor tendons are those on the palmar surface of the hand
Types
Open
- avulsion f.
- sharp injury
- laceration
Closed
- RA, Gout or hardware increased risk
- sports or job
Work up
- isolation test: hold dwn other fingers and ask to flex
- cascade: in flexiong: should be in line the fingers (not crossed)
- NV exam
- look for soft tissue, open wounds or fractures
Treatment
Non-op
- can try but most will end with gap or trigger
- immobilze with early ROM with OT
- cast: applied at wrist with MCP (knuckles) flexed slightly and IP joints extended
operative
- fix the tendon
Duputrens Contracture
Etiology
symptoms
treatment
complications
Etiology
- benign deformity of the hand as a resultof contracutres of the flexor tendon
- nodules or cords in the palm fibrose over time
- common in men 50-70 and its genetic
- ring or index finger commonly
Symptoms
- decreased ROM: affect ADLs
- painful nodules
Signs
- nodules in the tendonous band of the palmar surface
- hueston’s table top test : the finger rasies slightly off the table
treatment
Non op
- ROM eexercises, injections of bacteria (clostridium histolical) to eat and snap at the cord
Operative
- fasciectomy to remove the fibrosed tissue
Complications
- recurrance: liekly
- necorsis , hematoma
- raction
- NV injury
- digital ischemia
Trigger Finger
Etiology
Symptoms
Etiology
- mechanical impingment of the pull system in the finger sheath results in locking of the finger in a flexed position
Symptoms
- progresive pain
- clicking, locking and catching when moving
- ring and long fingers most likely
- tender at A1 pully
- palpable node
- reproducable click
- PIP joint fixed in a flexed position
Treatment (dx. clincially)
NonOp: splint, NSAIDS injection into sheath
Operative: release the A1 pully
Nail Bed Injury
sugungual hematoma
complications of injury
germinal nail bed : where the soft tissue deep to the nail sits, responsible for the nail develop: injury here could inhibit nail regrowth
injruy to any part, lateral nail folds, proximal nail fold (cutilce) etc.
- get Xray to see if underlying fracture
Subungual hematoma
- draing via. perforation : puncture and drain or electrocaut.
- nail removal, ID and nail bed repair if ** > 50% nail invovlement**
- during nail removal: can repair the bed with sutures and splint the fold for matrix regrowth
Complications
- hook nail
- split nail: damange to germinal matrix
-
Phalanx Fractures
Etiology
Symptoms/Findings
Diagnosis
Treatment
Etiology
- crush, axial load
- hyperextension/flexion
- direct blow
- lacteration
- twisting
Symptoms/Findings
- check NV injury
- cehck tendons
- disloaction, rotation, malaignment
- swelling, brusing pain decreased ROM
- see rotational deformities or an abnormal cascade
diagnosis
- xray to see fracture
- Tuft’s fracture: a fracture of the most distal phalanx
Treatment
- ice, elevation
- decided if stable or unstable fracture
Splinting
- distal phalanyx fx. : DIP in extensions 2-4 weeks
- middle: 4-6 weeks
- xrays to examine bone healing & ROM
- put wrist in slight extension, MCP in slight flextion & DIP/PIP in extension
Reduce if needed
if unstable, NV involvement, rotational or malalignment = refer
Digitial Dislocation
which way can dislocations occur
symptoms
how to reduce
Dislocations (always get an xray to see which way)
Dorsal: towards the back
volar: towards the palm
lateral: to the ulnar or radial side
SYmptoms
- pain swelling dec. ROM
- NV issues
- laxity of the joint
Treatment
Reduction
- anesthesias first and always
- reduce and then test stability of the joint and ROM
then Splint
- DIP injury: splint in full extension with PIP free
- PIP injury: splint with PIP at 30 degrees flextion
- voalr finger dislocation: splint PIP and DIp in ful exension
Metacarpal Fractures
Exam findings
Boxers fracture
key findin of metacarpal fracture is sissoring of the fingers due to displacement
Boxers Fracture
- a fracutre at the 5th metacarpal neck
Treatment = splining for small, nondisplaced boxers 2-3 weeks with movement
reduction: if needed
surgery if the angle of displacement is out of anatomical line
Genera Hand Infection
types
exam findings
treatment
Types
- cellulitis and lymphangitis
- paranychoia
- felon
- herpetic whitlow
- abscess
- flexor tenosynovitis
- deep space infections
- SA
Exam
- find dominate hand
- assess immunization status
- look at open wounds, alignment of fingers and tenderness
- watch for necrotizing fascititis
- LAN
- systemic signs (get labs)
Treatment
- antibiotics
- I & D for those purulent
- surgery: SA, flexor teno and deep sapce
- elevation
- warm soapy soaks
- vaccines UTD
Paronychia
Felon
Paronychia
- soft tissue infection of the proximal and lateral nail fold
- common hand infection
- pain, redness, swellingg, nail discoloration
- treatmet = soapy soaks, Abx. I7D, can remove nail
Felon
- subcut. abcess of the fingertip pulp
- injury penitration, local spread possible
- severe thobbing pain and open wound
- Treatment = I & D and Abx.
Deep Space Infections
- infections of the thenar, midpalmar and hypothemar spaces & collar button abcessess
Presentation
- swelling, pain with flextion loss of palmar concavity due to swelling
Treatment
- operative I & D and abx. IV
Herpetic Whitlow
** viral infection casues by HSV-1**
- toddlers and healthcare
presentation
- intesne burning and followed by redness and a small vesicular rash
Treatment
- obeservation and acyclovir if it doesnt go away
